Differential Diagnosis For

Rash and Fever

dr. Irma Suswati, M.Kes

How do you describe this

rash?

Multiple erythematous macules and/or papules, a few millimeters to 1 cm in size

coalescing together. Symmetric distribution on trunk, extremities, and
Intertriginous area.

Derm Lingo

Macule: flat, nonpalpable circumscribed area of change in the skin

color, may be any size.
Papule: small solid elevation of skin generally < 5 mm in diameter.
Plaque: palpable, plateau-like elevation of skin > 5mm in diameter.
Nodule: palpable, solid, round, or ellipsoidal lesion > 5 mm diameter.
Vesicle (blister): circumscribed, elevated lesion that is < 5 mm in
diameter containing serous (clear) fluid.
Bulla: A vesicle with a diameter > 5 mm.
Pustule: superficial, elevated lesion that contains pus.
Cyst: an epithelial lined cavity containing liquid or semisolid material.
Wheal: transitory, compressible papule or plaque of dermal edema

How do you describe this

rash?

Multiple tense vesicles and bullae around the axilla.

Describing a Rash

Color
Margination
Shape
Palpation
Number
Arrangement
Confluence
Distribution

The Presence of Fever & Rash

should raise the following
questions?

Site of onset, rate & direction of spread.

Distribution, configuration and arrangement of the
lesion?
Is there erythema, hypo, or hyperpigmentation?
Are there secondary characteristics such as scale?
Is pruritus present?
Is the patient taking any meds (prescription, OTC,
herbal)
Travel History?
Immune Status?

Differential Dx for
maculopapular Rash and Fever

Viral Exanthems: rubeola, rubella, erythema

infectiosum (Parvo), roseola (HHV-6),
Coxssackievirus, echovirus, EBV, adenovirus,
dengue, CMV,
Bacterial Infections: Strep pyogenes (Scarlet
Fever), Staph aureus (TSS), Meningococcemia
Other Infections: Sec Syphilis
Drug Eruption: (penicillin, tetracyclines,
sulfonamides, dilantin, barbituates,
phenylbutazone, NSAIDS, salicylates)
Erythema Multiforme
Rheum: SLE, Reiters Syndrome

MEASLES - RASH

CDC - B.Rice

Murray et al. Medical Microbiology

MEASLES - Kopliks spots

Murray et al. Medical Microbiology

RUBELLA

Murray et al. Medical Microbiology

Parvovirus pathogenesis

A "slapped-cheek" appearance is typical of the rash for erythema infectiosum.(From Medical

Microbiology, 5th ed., Murray, Rosenthal & Pfaller, Mosby Inc., 2005, Fig. 56-5.)

SLAPPED-CHEEK SYNDROME

Coxsackievirus,
Echovirus
Exanthems
Morbilliform rashes

Fine, erythematous, maculopapular

rashes
Common in summer months
Rash appears simultaneously with fever
and starts on face
Associated with echovirus 9

Coxsackievirus,
Echovirus

Roseoliform rashes

Discrete, nonpruritic, salmon-pink macules

and papules on the face and upper chest
Prodrome of fever and pharyngitis
Rash appears after defervescence and lasts
1-5 days
Contagious especially amongst young
children
Echovirus 16 most commonly associated

Coxsackievirus,
Echovirus

Generalized vesicular eruptions

Most frequently caused by

coxsackievirus A9 and echovirus 11
Lesions look like those of hand-foot-andmouth but occur in crops on the head,
trunk and extremities
Do not evolve into pustules or scabs
(unlike chickenpox)

Coxsackievirus,
Echovirus

Herpangina

Vesicular rash involving pharynx and

soft palate
Summer outbreaks of group A
coxsackievirus
Fever, vomiting, myalgia and headache
associated with prodrome

Coxsackievirus,
Echovirus

Hand-foot-and-mouth disease

Distinctive vesicular eruption usually

caused by coxsackie A16 or enterovirus 71
Most common in children under age 10
Fever and vesicles in the mouth and on
the hands and feet
Can look like chickenpox but illness is
generally milder

Scarlet fever

Staphylococcus scalded skin

syndrome

Toxic shock syndrome

Differential Diagnosis for

Bullous Rash

Viral (HSV, Coxsackie, Varicella & Herpes Zoster)

Bacterial (Staphylococcal) Bullous Impetigo
Drug Rxn
Allergic Contact Dermatitis
Insect Bite
Porphyria Cutanea Tarda
Autoimmune blistering diseases of the skin:

Intraepidermal bullous diseases: Pemphigus vulgaris,

Pemphigus foliaceus, Paraneoplastic pemphigus
Subepidermal bullous diseases: Bullous Pemphigoid, Herpes
Gestationis, Cicatricial Pemphigoid, Epidermolysis Bullosa
Acquisita, Linear IgA Bullous Dermatosis

VZV
Clinical Presentations
Primary infection = varicella (chickenpox)

14 day incubation period

Characterized by generalized fever and
vesicular lesions
Usually self-limiting in normal children
More severe in adults and
immunocompromised persons
Mechanism of latency not as well understood
as for HSV

VZV
Clinical Presentations
Reactivation in adults = zoster (shingles)

Painful unilateral vesicular rash

Dermatomally distributed (T3-T12; L1-L2; V1)
Vesicles usually resolve in 2-3 weeks
scarring possible
Most common complication: post-herpetic
neuralgia
More severe, often disseminated in
immunocompromised persons encephalitis

Herpes

Herpes Simplex