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CHAPTER 35
RASH AND FEVER

History 234
A rash is a visible lesion of the skin due to disease.
Physical examination 234 The condition can be a primary skin disorder or a
Important rashes in the newborn 235 symptom of a systemic process. Rashes caused by
Erythema toxicum 235 infection can be limited to skin involvement or be part
Staphylococcal skin infection 235 of a broader condition.
Localized herpes simplex virus (HSV) infection 235 When considering the differential diagnosis of a
Varicella zoster virus infection 236 rash, it is important to be able to describe its features.
Petechiae 236 Ask the child’s parents about the appearance, because
rashes often change with time.
Rashes in infancy and childhood 236
Vesicular rashes 236
Maculopapular rashes 237 History
Petechial and purpuric rashes 238
Papular rashes 239 ■ Onset of the rash: sudden or gradual.
Generalized erythroderma 240 ■ Type of lesion: see Table 35.1.
Urticaria 241 ■ Distribution: whether central, peripheral or
Clinical problem 243 generalized.
■ Progression: direction of spread, speed of
progression.
■ General well-being of the child, including prodro-
mal illness or fever.
■ Infectious contacts.
■ Drug history: including over-the-counter prepara-
tions, topical treatments and drugs that have been
ceased.
■ Symptoms of the rash: itch, pain, burning.
■ Travel history.
■ Contact with pets and other animals.

Physical examination

Be sure to examine:
■ The entire skin surface:
– To determine the true extent of the rash.
– Type of lesions.
– Distribution.
– Evolving lesions.
■ The mucous membranes for involvement or
ulceration.
■ The conjunctivae for injection or episcleritis.

234
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Important rashes in the newborn 235

Table 35.1 Terminology of cutaneous lesions

Type of lesion Description Common causes
Vesicles Small, fluid-filled blisters Varicella zoster, herpes simplex, enteroviruses
(particularly Coxsackie A)
Petechiae Small, non-blanching spots Vasculitis, meningococcaemia, thrombocytopenia
Pustules Small blisters containing purulent fluid Bacterial infection, e.g. Staphylococcus aureus.
NB: not necessarily infective
Urticaria Raised, itchy lesions Drug eruptions, erythema marginatum, idiopathic
Macules Flat spots, not palpable. Can form Drug eruptions, viral exanthems
large sheets
Papules Elevated, palpable, small rounded Molluscum contagiosum, warts, enteroviruses
lesions
Plaques Elevated, flat-topped lesions Psoriasis, pityriasis rosea

■ The scalp and hair for areas of inflammation,
scaling or hair loss. Use of ultraviolet light (a
Wood’s light) can show fluorescence in some types
of fungal infection.
■ For lymphadenopathy.
■ For hepatosplenomegaly.
■ The joints for any associated arthritis.
Important rashes of infancy and childhood that are
commonly seen in general paediatric practice will
be discussed in the following section under descrip-
tive headings, with a separate section for neonatal
conditions.
Important rashes in the newborn
Erythema toxicum
widespread skin loss (Fig. 35.1). This condition is life
threatening.
Localized herpes simplex virus (HSV)
infection
Neonatal HSV infection may be localized, at least
initially, to the skin, eyes and/or mouth, so-called
skin–eye–mouth (SEM) disease. Vesicles are most
often found on the scalp or around areas of minor
trauma, e.g. scalp electrode sites. They can present as
shallow ulcers only. Rapid diagnosis can be obtained,
often within an hour or two, using specific immuno-
fluorescent staining of cells swabbed from the base of
a lesion. Polymerase chain reaction (PCR) for viral
DNA is not usually helpful in this situation because of

This appears as red macules with overlying small

yellow or white pustules. The condition is idiopathic
and non-infective. It can be mistaken for infection: a
Gram stain of the lesion shows multiple eosinophils.
The rash often appears during the first few days of life
and may persist up to a fortnight.

Staphylococcal skin infection

This can look similar to erythema toxicum: the skin

may be indurated and pustules may be interspersed
with vesicles and sometimes bullae. When bullous, it
is referred to as bullous impetigo. In its most severe
form, of staphylococcal scalded skin syndrome, there
is extensive erythema in a clinically septic child, with
Fig 35.1 Staphylococcal scalded skin syndrome in a
neonate. Skin desquamation with underlying
erythema. (Courtesy of Dr Maureen Rogers.)
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236 Rash and fever

time constraints. Urgent early treatment of localized has remained latent in nerve cells following earlier
neonatal HSV infection with intravenous acyclovir is chickenpox. The rash is characteristic, with the erup-
essential because, without treatment, 70% of affected tion of crops of vesicles in a dermatomal distribution,
babies will progress to disseminated HSV infection although there are often one or two spots outside the
with encephalitis, hepatitis, DIC and an extremely dermatome. Confusion with herpes simplex stomati-
poor prognosis. tis may occur when facial nerve dermatomes are
involved. Pain is surprisingly rare in children, although
older children may sometimes have painful lesions.
Varicella zoster virus infection
Although zoster is common in immunocompromised
children, it is not uncommon in normal children, and
Neonatal varicella is usually seen in the context of
is virtually never the first presentation of underlying
maternal chickenpox (or more rarely zoster) or of
malignancy or immune compromise. Zoster in young
contact with an infected sibling. Rapid diagnosis can
children often results from having chickenpox in the
be obtained by specific immunofluorescence of vesicle
neonatal period, or from intrauterine exposure due to
fluid. Neonatal varicella resulting from perinatal
maternal VZV in pregnancy.
transmission can be life threatening and, if severe,
requires intravenous acyclovir.
Herpes simplex virus (HSV)
Petechiae While HSV infection is often asymptomatic, the most
common presentation during childhood is with gin-
The most common cause of neonatal petechiae is givostomatitis. The child is febrile and develops ulcers
thrombocytopenia, either from platelet destruction by of the gums, buccal mucosa and pharynx, and often
maternal antibodies, or from congenital infection such on the cheek where saliva dribbles. There may be
as CMV. Congenital rubella is extremely rare in most marked facial swelling and redness. Involvement of
developed countries, because of immunization. a finger can occur (herpetic whitlow), and may
mimic paronychia. HSV infection of eczematous skin
(eczema herpeticum) can spread rapidly (Fig. 35.2)
Rashes in infancy and childhood
and, if the vesicular nature of the lesions is overlooked,
may be misdiagnosed as worsening eczema or bacter-
Vesicular rashes
ial superinfection. A clinical diagnosis of eczema
herpeticum can be confirmed rapidly with specific
Varicella (chickenpox)
Chickenpox is caused by primary infection with vari-
cella zoster virus (VZV). Classically, there is a short
prodrome of about a day of sore throat and fever, after
which varicella commences as crops of itchy, circum-
scribed, vesicular lesions on the scalp and trunk. These
become pustular before becoming crusted and then
resolve without scarring, if not superinfected. A range
of lesions at different stages is usually seen at any one
time. Mucous membranes may be involved. There is
often only a mild prodromal illness of fever and mild
lethargy. When varicella occurs in the context of sig-
nificantly damaged skin, such as eczema, the risk of
serious illness is much higher, and careful monitoring
and treatment are indicated.

Herpes zoster (shingles)

Fig 35.2 Eczema herpeticum. Widespread
Zoster is caused by the same virus as chickenpox – inflammation, but discrete vesicular lesions are
VZV – but occurs due to reactivation of VZV, which distinguishable.
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Rashes in infancy and childhood 237

immunofluorescence, and affected children usually

require intravenous acyclovir.

Enteroviruses
Non-polio enteroviruses are a common cause of
vesicular rashes, especially in summer and autumn.
Hand, foot and mouth disease is caused by different
enteroviruses, most commonly Coxsackievirus type
A16. It often occurs in epidemics in daycare centres or
schools. It is associated with a papulovesicular erup-
tion on the palms, soles, mucous membranes and
sometimes the buttocks. There may be mild associated
respiratory or gastrointestinal symptoms, but the clin-
ical course is benign.
Enterovirus 71 can cause hand, foot and mouth
disease, but differs from the other enteroviruses in that
infections may be accompanied by significant neuro-
logical manifestations, such as aseptic meningitis,
brainstem encephalitis with neurogenic pulmonary
oedema, and acute flaccid paralysis.

Impetigo
Impetigo is the most common skin infection encoun-
tered in infants and school-aged children. It is caused
by Streptococcus pyogenes or Staphylococcus aureus. The
early lesion is an erythematous papule, which
progresses to transient vesicles and then becomes a
shallow ulcer with surrounding honey-coloured
crusted exudate. The lesions are often found in an area
of traumatized skin, and are commonly around the
nose, mouth and extremities. It is spread among indi-
viduals through close physical contact.
Maculopapular rashes
Many virus infections, especially enteroviruses,
produce maculopapular exanthems. These are often
non-specific and generalized in distribution (Fig.
35.3). They can be difficult to differentiate from aller-
gic drug reactions. Features that favour a viral aetiol-
ogy are:
■ Occurrence along scratch marks.
■ Some lesions in straight lines.
■ Exaggeration in areas of sunburn.
■ Occurrence under hospital arm bands or on prior
skin disease.
■ Presence of lymphadenopathy.
Fig 35.3 Viral exanthem. Widespread macules,
some in a characteristically linear pattern.
Measles
Measles is rare in countries with high levels of immu-
nization. While the diagnosis should be considered in
a child with a blotchy, geographical, erythematous
exanthem, other causes are usually more likely in an
immunized child. Characteristic features of measles
are:
■ 3–5 days of prodromal features of fever, malaise,
conjunctivitis, coryza and cough.
■ High fever, which persists after the rash appears.
■ Downward spread of the rash from the pre-
auricular area and the face to involve the body.
■ Tendency of the rash to become confluent on the
trunk and remain discrete lower down.
■ Tendency of the rash to become brown and then
desquamate after 2–3 days.
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238 Rash and fever

Rubella associated with arthralgias. This form of the rash may

wax and wane for weeks after the initial illness. Children
Rubella virus infection results in an erythematous, dis-
are no longer infectious once the rash has appeared.
crete exanthem that is often faint but may be morbil-
liform (measles-like) and spreads down from the face.
Occipital and/or post-auricular lymphadenopathy is Roseola infantum
typically (but not exclusively) associated, and arthritis
Roseola is a condition that affects infants and young
and conjunctivitis can occur. There are relatively few
children. Children initially have 3–5 days of high fever
systemic symptoms in children. It is important to trace
and mild systemic symptoms, before the rash then
and investigate pregnant contacts of a case.
appears with simultaneous defervescence. The rash
consists of small rose-pink macules or papules, which
Kawasaki disease may be morbilliform and are most prominent on the
trunk and face. The most common aetiological agent
This is an important differential diagnosis of a child
is human herpesvirus 6 (HHV-6). Children with
with rash and fever. Clinical features include persistent
measles are febrile and miserable when the rash is
high fever with characteristic marked irritability,
present; in contrast, the child with roseola becomes
rash, cervical lymphadenopathy (sometimes unilateral
afebrile and well as the rash appears.
resembling abscess), non-exudative conjunctivitis,
stomatitis, and swelling or redness of hands and feet.
The rash is not specific and can take many forms. It Meningococcal infection
may resemble erythema multiforme, scarlet fever,
A transient macular rash, mimicking an enteroviral
measles, urticaria or a drug reaction. It is usually non-
rash, can occur early in infection with Neisseria menin-
pruritic, and may be transient or evanescent (comes
gitidis in up to 20% of cases. It typically disappears in
and goes).
less than a day, and purpura may then appear.

Erythema infectiosum (slapped cheek disease, Petechial and purpuric rashes (Table 35.2)
fifth disease)
Parvovirus B19 infection produces a rash that develops Meningococcal infection
in two stages. The initial appearance is of ‘slapped
In a febrile child without an infectious focus, a local-
cheeks’: an intense erythema of the malar areas resem-
ized petechial or purpuric rash can be the first sign of
bling sunburn in a child who may be well, or have mild
N. meningitidis septicaemia (Fig. 35.5). The lesions
systemic symptoms of malaise and fever. The patient
may be very subtle early in the course. Purpuric lesions
then develops a reticulated macular erythema over the
limbs (Fig. 35.4). This is often asymptomatic or may be

Table 35.2 Differential diagnosis of child with

purpura or petechiae
Bacterial infections
Neisseria meningitidis
infection
Staphylococcus aureus
sepsis
Streptococcus pneumoniae
sepsis
Listeria monocytogenes
sepsis
Group A streptococcal
Fig. 35.4 Fifth disease. Lacy, reticular rash. pharyngitis
(Courtesy of Dr Maureen Rogers.)
Other causes
Viral illnesses, e.g.
enteroviruses,
EBV, CMV
Rickettsial infections
Henoch–Schönlein
purpura
Thrombocytopenia
(ITP, malignancy)
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Fig 35.5 Purpura. Discrete purple lesions > 2 mm in
diameter, which will not blanch on pressure.
do not blanch with pressure. A simple test is to press
a glass slide or a drinking glass on the lesions and
observe through the glass whether the lesions stay
purple or go white (blanch).
Henoch–Schönlein purpura (HSP)
HSP is an immunologically mediated vasculitis,
thought to be a reaction to an infectious agent,
although no single organism has been implicated. It
is usually preceded by an upper respiratory tract
infection. It is the most common cause of non-
thrombocytopenic purpura in children. The rash
characteristically involves the buttocks and extensor
surfaces, starting off as pink, blanching macu-
lopapules, which progress to palpable non-blanching
purpura that evolves from red to purple and then
brown, before fading over 2–3 days. The lesions occur
in crops and may recur at intervals over days to
months after the initial episode. Fever is uncommon.
Idiopathic thrombocytopenic purpura (ITP)
ITP is an immunologically mediated disease, in which
platelet destruction by auto-antibodies leads to
petechiae, and occasionally a purpuric rash with frank
bleeding. Many different viral infections can some-
times be triggers for the occurrence of ITP (which is
not really idiopathic in those cases). Children are not
usually febrile at the time of onset of the rash of ITP.
Leukaemia
Children with marrow infiltration by malignant cells,
particularly leukaemia, may present with a petechial
Rashes in infancy and childhood 239
rash. This is usually accompanied by a history of easy
bruising, malaise or fatigue, bone pain, and often
pallor caused by the associated anaemia. Fever may
also be present due to infection.
Papular rashes
Molluscum contagiosum
Molluscum is a poxvirus infection, which causes mul-
tiple, 2–5 mm diameter, flesh-coloured papules with
a central dimple (umbilication). Initially firm, the
lesions become softer and waxier with time. Some
lesions have a mildly erythematous base and lesions
may become superinfected. The lesions can occur on
all parts of the body, but are least common on the
palms or soles. Auto-inoculation and spread to others
via close contact can occur. In the vast majority of
cases, the condition will resolve over some months
without specific treatment. Immunodeficiency, e.g.
HIV, predisposes to severe molluscum.
Acral papular viral exanthem
While classically attributed to the exanthem associated
with hepatitis B (Gianotti–Crosti syndrome), acral
papular exanthems can occur with a number of virus
infections, especially enteroviruses. There are many
terms used for this exanthem, including papular acro-
dermatitis of childhood and papulovesicular acrolo-
cated syndrome (PALS). The appearance is of papular
and occasionally vesicular lesions, restricted to the
acral part of the limbs and occasionally the face (Fig.
35.6). There is often associated pruritus. The predom-
inant age group affected is 2- to 4-year-olds. The reac-
tion has a prolonged course and may take up to 10
weeks to resolve.
Erythema multiforme (EM)
EM is characterized by an abrupt eruption of erythe-
matous macules or plaques, usually most prominent
on the extensor surfaces of the upper limbs (Fig. 35.7).
The diagnostic lesion is doughnut shaped, with an ery-
thematous outer ring, and a pale inner ring around a
dusky or necrotic centre (target lesions). The lesions
are mostly asymptomatic, but may be mildly uncom-
fortable or pruritic. The lesions remain fixed in posi-
tion, and are often characteristically symmetrical
bilaterally. They fade after a week to 10 days. Oral
lesions may occur (but other mucosal surfaces are not
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240 Rash and fever
Fig 35.6 Acral papular viral exanthem. Raised
papules on the hands of a child. (Courtesy of Dr
Maureen Rogers.)
Fig 35.7 Erythema multiforme. Oval, erythematous
‘target’ lesions with dusky centres. (Courtesy of Dr
Maureen Rogers.)
involved), and 25% of cases involve the oral mucosa
alone. The most common infective cause is HSV.
Stevens–Johnson syndrome
An important differential of EM, this eruption differs
in that two or more mucosal surfaces are involved,
lesions are more widespread, and there is progression
to bulla formation and haemorrhagic crusting (Fig.
35.8). Mucosal ulceration of the mouth and genitalia
may occur and is severely painful. There is often sig-
nificant internal organ involvement and a prodrome
of flu-like upper respiratory tract illness. The most
common infectious agent implicated is Mycoplasma
pneumoniae; the other major causal agent is drugs.
Fig 35.8 Stevens–Johnson syndrome. Haemorrhagic
lesions, some bullous, plus severe mucosal
involvement.
Generalized erythroderma
Staphylococcal scalded skin syndrome
This manifestation of S. aureus infection is mostly seen
in children under 5 years. Foci of infection include the
nasopharynx, urinary tract, umbilicus and skin abra-
sions. The skin reaction is mediated by staphylococcal
epidermolytic toxin A or B. It consists of a scarlatini-
form, generalized erythroderma, accompanied in
severe forms by internal organ involvement and severe
systemic illness. The child may be irritable and unwell;
the erythroderma is markedly tender and may
progress to take on a wrinkled appearance, before
forming sterile bullae and erosions, with extensive epi-
dermal loss. The conjunctivae may be erythematous
and purulent, and radial fissuring is common around
the mouth, nose and eyes. Perioral erythema is promi-
nent. Owing to skin loss, fluid and electrolyte imbal-
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Rashes in infancy and childhood 241

ances and secondary infection are common complica-

tions. The split in the skin layers is superficial, so that
with antibiotic treatment complete recovery occurs
with no scarring.

Scarlet fever
Scarlet fever is a systemic manifestation of Streptococ-
cus pyogenes infection, resulting from exotoxin pro-
duction. It affects mainly children aged 3–12 years and
is rare in infancy. Scarlatina is the name given to a
milder illness in which streptococcal infection causes
scarlatiniform rash alone, without the systemic fea-
tures. True scarlet fever causes an erythematous, fine,
punctate rash which characteristically has a sandpaper
texture. It appears initially on the trunk and spreads
rapidly. Petechiae may be found on major skin folds.
Other distinctive features are glossal inflammation,
with prominent papillae (a ‘strawberry tongue’) and
circumoral pallor, with the rash sparing the skin
around the mouth. There is often desquamation of
fingers and toes on resolution.
Fig 35.9 Purple urticaria. Blotchy truncal rash,
purple in places. (Courtesy of Dr Maureen Rogers.)
Toxic shock syndrome (TSS)
Like scarlet fever, TSS is a severe, systemic, clinically
defined reaction to bacterial toxin. By definition, clin- Erythema marginatum
ical features must include high fever, rash with desqua-
mation, hypotension and involvement of at least three The rash associated with rheumatic fever (RF) is a
organ systems. Organisms associated with this syn- form of urticaria. It manifests in around 10% of
drome are S. aureus and S. pyogenes. While TSS is patients with RF, and is considered one of the major
usually recognized by the combination of all symp- diagnostic criteria for RF when present. The rash has
toms, the rash is typically a diffuse erythroderma, and an erythematous macular component and a raised
may be accompanied by conjunctival and other edge (Fig. 35.10). It is non-pruritic and non-painful,
mucous membrane hyperaemia. Its distribution and and the lesions coalesce to form a serpiginous pattern.
intensity may alter from hour to hour during the
course of the illness.

Urticaria

It is important to appreciate that, while classically

associated with hypersensitivity reactions, urticaria
in children under 5 years of age is most commonly
caused by a viral illness. In this situation, there is often
less associated pruritus than would be expected with
an allergic reaction. Severe lesions may be associated
with a purple discoloration due to bruising (purple
urticaria; see Fig. 35.9). Viral urticaria differs from
erythema multiforme because the position of the Fig 35.10 Erythema marginatum. Widespread
lesions changes, and the erythema disappears from urticarial rash with thin, pink margin. (Courtesy of Dr
individual lesions over a 24-hour period. Maureen Rogers.)
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242 Rash and fever

The rash may be fleeting and may reappear intermit-
tently over weeks.
Drug reactions
Cutaneous manifestations are the most common form
of adverse drug reaction in children. While classically
drug reactions are urticarial in nature, almost all mor-
phological variants are possible. Angioedema related
to drug ingestion is more significant, as it implies an
IgE-mediated pathway for the reaction and hence pos-
sible risk of anaphylaxis on re-exposure.
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Clinical problem
A 3-year-old girl was brought by ambulance to
the emergency department after a seizure at home.
On the day of presentation, she had been non-
specifically unwell. In the afternoon she complained
of a few non-specific aches and pains, and was
anorexic. Her mother thought she felt hot. She had
vomited once during the evening. She had no
rhinorrhoea, cough or rash. Just after midnight she
had a brief generalized tonic–clonic seizure and
was brought to hospital.
Her only significant medical history was of a
febrile convulsion at 18 months of age, from which
she had recovered uneventfully. She had been born
at term, with no perinatal complications. Her
immunizations were up to date. She had no
siblings.
On examination in the emergency department
Questions
1. What is the likely diagnosis?
2. What is the differential diagnosis of a child with
fever and petechiae?
Clinical problem 243
she was sleepy but easily rousable. Her temperature
was 39.4∞C, her heart rate was 130 beats per
minute and respiratory rate 24 breaths per minute.
Her throat was slightly red and there were a few
petechiae around her left eye. The remainder of
the examination was normal. Her blood sugar was
6.1 mmol/L. A diagnosis of febrile convulsion was
made and she was observed overnight. The
petechiae around her eye were considered to be
secondary to her vomiting. She vomited several
more times overnight.
On review the next morning she was sitting up
in bed watching television, but her father was
concerned that she did not seem well. On closer
examination she had further petechiae around her
face and a spreading purpuric rash was found over
her legs and chest.
Discussion
1. The most likely diagnosis in this child is
meningococcal septicaemia. The main clinical
features of meningococcal disease at
presentation are fever (88%), rash (68%),
vomiting (67%) and drowsiness (55%). Early
recognition of this condition is vital for
successful treatment. The classic spreading
purpuric rash discovered in this child is virtually
pathognomonic. Earlier diagnosis based on the
scattered petechiae around her eyes would have
required a higher degree of clinical suspicion.
■ Meningococcal disease may present with a
petechial rash alone, a maculopapular rash or no
rash. Atypical presentations may lead to delayed
diagnosis and a worse outcome.
2. There is a wide differential diagnosis to be
considered in the child presenting with fever
and petechiae. Only about 10% of children
presenting to hospital with fever and petechiae
in the USA and UK have meningococcal
infection.
■ Risk factors for serious bacterial infection in these
children include: appearing unwell or toxic,
signs of meningism, lack of pharyngitis,
numerous petechiae, the presence of purpura
and high (>15 ¥ 109/L) or low (<5 ¥ 109/L)
white cell counts. In the absence of these risk
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244 Rash and fever

factors, much diagnostic information can be

3. What should be the immediate diagnostic and
therapeutic steps?
4. Is there a rapid diagnostic procedure available?
obtained by a period of close observation,
looking for progression of or appearance of a
rash, the development or persistence of fever or
any deterioration in general condition. It is
important to periodically re-examine the skin
closely to detect any new changes early.
3. Appropriate diagnostic procedures in this child
would include a full blood count, blood cultures,
throat swab for bacterial culture, culture of skin
lesions for meningococcus, a lumbar puncture if
there was any suspicion of meningitis and blood
PCR for meningococcus if available. This latter
test can be particularly valuable when antibiotics
have been given prior to blood cultures being
obtained.
■ In this child, a full blood count showed an
elevated white cell count of 15.1 ¥ 109/L, with
13.3 ¥ 109/L neutrophils. A Gram stain of the
serosanguineous fluid expressed from one of the
purpuric skin lesions showed Gram-negative
diplococci. Lumbar puncture was not performed.
She responded rapidly to intravenous penicillin
G. Blood and throat swab cultures were
negative, but blood PCR for N. meningitidis was
positive.
4. Gram staining of films obtained from petechial
lesions is an extremely useful diagnostic aid,
with a sensitivity of up to 80%. It can be
performed by pricking one of the purpuric spots
and squeezing some fluid from the spot onto a
slide for staining.
■ Intravenous or intramuscular antibiotic should be
given as soon as possible in suspected
meningococcal disease. Diagnostic procedures
(including lumbar punctures) should not delay
giving antibiotics by any longer than 15–20
minutes. Children with meningococcal infection
require close monitoring, generally in an
intensive care setting, as they can deteriorate
rapidly due to toxaemia and cardiomyopathy.

A final diagnosis of meningococcal infection was

made.