FEVER AND RASH

ALVIN GERMO
PASUQUIN
 TABLE OF CONTENTS

01 FEVER FEVER OF
UNKNOWN

02 FEVER AND RASH

ORIGIN
03
 Fever is an elevation of body temperature
that exceeds the normal
daily variation and occurs in conjunction
FEVER with an increase in the hypothalamic set
point (e.g., from 37°C to 39°C).
• The mean oral temperature is 36.8° ± 0.4°C (98.2° ± 0.7°F), with low levels
at 6 a.m. and higher levels at 4–6 p.m. The maximal normal oral temperature
is 37.2°C (98.9°F) at 6 a.m. and 37.7°C (99.9°F) at 4 p.m.;
• An a.m. temperature of >37.2°C (>98.9°F) or a p.m. temperature of >37.7°C
(>99.9°F) would define a fever.
• The normal daily temperature variation, also called the circadian rhythm, is
typically 0.5°C (0.9°F).
• In some individuals recovering from a febrile illness, this daily variation can
be as great as 1.0°C.
• Rectal temperatures are generally 0.4°C (0.7°F) higher than oral readings.

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HYPERPYREXI
A
• A fever of >41.5°C (>106.7°F)
• This extraordinarily high fever can develop in patients with severe infections but most commonly
occurs in patients with central nervous system (CNS) hemorrhages.
PATHOGENESIS OF
FEVER
The term pyrogen (Greek pyro, “fire”) is used to describe any substance that causes fever.
Most are microbial products, microbial toxins, or whole microorganisms (including viruses).

Example of an exogenous pyrogen:

Lipopolysaccharide (endotoxin) produced by all gram-negative bacteria.
Pyrogenic products of gram-positive organisms include the enterotoxins of Staphylococcus aureus and
the groups A and B streptococcal toxins
FEVER AND
RASH
APPROACH TO THE PATIENT
01 IMMUNE STATUS / IMMUNIZATION STATUS

02 MEDICATIONS TAKEN WITHIN THE PREVIOUS MONTH

03 TRAVEL HISTORY

04 EXPOSURE TO ANIMALS / HX OF ANIMAL BITES

05 EXPOSURE TO ILL INDIVIDUALS

06 SEXUAL EXPOSURE
APPROACH TO THE PATIENT
07 RECENT DIETARY EXPOSURE

08 EXISTENCE OF CARDIAC ABNORMALITIES

09 PRESENCE OF PROSTHETIC MATERIAL

10 THE SITE OF ONSET OF RASH

11 DIRECTION AND RATE OF SPREAD

MACULES
flat lesions defined by an area OF
blanchable erythema
PAPULES
raised, solid lesions <5 mm in
diameter
PLAQUE
lesions >5 mm in diameter with a
flat, plateau-like surface
NODULES
lesions >5 mm in diameter with a
more rounded configuration
WHEALS
papules or plaques that are pale pink
and may appear annular (ringlike)
as
they enlarge; classic (nonvasculitic)
wheals are transient, lasting
only 24 h in any defined area.
VESICLES (<5 mm)
are circumscribed, elevated lesions
containing fluid.
BULLAE (>5 mm)
are circumscribed, elevated lesions
containing fluid.
PETECHIAE Nonpalpable
purpura is a flat lesion that is due to
bleeding into the skin that is <3 mm
in diameter,
ECCHYMOS
ES Nonpalpable
purpura is a flat lesion that is due to
bleeding into the skin that is >3 mm
in diameter,
PUSTULES
raised lesions containing purulent
exudate
 PALPABLE
PURPURA
a raised lesion that is
due to inflammation of the vessel
wall (vasculitis) with subsequent
hemorrhage. An
ULCER
is a defect in the skin extending at
least into
the upper layer of the dermis
ESCHAR a necrotic
lesion covered with a black crust.
CLASSIFICATI
ON OF RASH
 CENTRALLY PERIPHERAL CONFLUENT VESTIBULOU
DISTRIBUTED DESQUAMATI S OR
MACULOPAP VE PUSTULAR
UPLAR ERYTHEMA

URTICARIAL NODULAR PURPURIC ERUPTIONS

LIKE ERUPTIONS ERUPTIONS WITH
ULCERS AND
ESCHARS
 ● ERYTHEMA
INFECTIOSUM
● PRIMARY HIV INFECTION
● INFECTIOUS
MONONUCLEOSIS
● ROSEOLA
● ZIKA VIRUS
● SLE
CENTRALLY DISTRIBUTED ● ERYTHEMA MARGINATUM
● DENGUE
● TYPHOID
● LEPTOSPIROSIS
 RUBEOLA /
MEASLES
The rash starts at the hairline 2–3 days into the illness and moves down
the body, typically sparing the palms and soles.
 It begins as
discrete erythematous lesions,
which become confluent as the
rash spreads.
Koplik’s spots (1- to 2-mm white
or bluish lesions with an
erythematous halo on the buccal
mucosa) are pathognomonic for
measles and are generally seen
during the first 2 days of
symptoms.
 RUBELLA / GERMAN
MEASLES
Rubella (German measles) also spreads from the hairline downward;
unlike that of measles, however, the rash of rubella tends to clear from
originally affected areas as it migrates, and it may be pruritic.
Postauricular and suboccipital adenopathy and arthritis are common
among adults with rubella. Exposure of pregnant women to ill individuals
should be avoided, as rubella causes severe congenital abnormalities.
unlike that of measles, however, the
rash of rubella tends to clear from
originally affected areas as it
migrates, and it may be pruritic.
Forchheimer spots (palatal
petechiae) may develop but
are nonspecific
DENGUE

Rash in 50% of cases; initially diffuse

flushing; midway through illness, onset of
maculopapular
rash, begins on trunk and spreads
centrifugally to
extremities and face
 TYPHOID
FEVER
Transient, blanchable
erythematous macules and
papules, 2–4 mm, usually on
trunk (rose spots)
 LEPTOSPIROSIS
Maculopapular eruption;
conjunctivitis; scleral
hemorrhage in some cases
PRIMARY HIV
INFECTION
SLE
Macular and papular erythema, often
in sun-exposed areas;
discoid lupus lesions; periungual
telangiectasis; malar rash;
vasculitis sometimes causing
urticaria, palpable purpura; oral
erosions in some cases
 ● CHIKUNGUNYA
● ERYTHEMA MULTIFORME
● HAND-FOOT-MOUTH
DISEASE
● BACTERIAL ENDOCARDITIS
● SECONDARY SYPHILIS
PERIPHERAL
CHIKUNGUNYA
Maculopapular eruption;
typically occurs on trunk,
but also occurs on
extremities and face
 HAND FOOT MOUTH DISEASE

Tender vesicles, erosions

in mouth; 0.25-cm papules
on hands and feet with rim
of erythema evolving into
tender vesicles; shedding
of nails can occur 1–2
months after acute illness;
coxsackievirus A6 lesions
extend to perioral area,
extremities, trunk
buttocks, genitals, and
areas affected by eczema
BACTERIAL ENDOCARDITIS
Subacute: Osler’s nodes; petechiae on skin
and mucosa; splinter hemorrhages.
Acute :Janeway lesions
ERYTHEMA MULTIFORME
Target lesions (central erythema
surrounded by area of clearing and
another rim of erythema) up to 2 cm;
symmetric on knees, elbows, palms, soles;
spreads
centripetally; papular, sometimes
vesicular;
SECONDARY SYPHILIS
scaly papular eruption, diffuse but
prominent on palms and soles; rash never
vesicular in adults;

Rash that appears from 2 to 8 weeks after

the chancre develops and sometimes
before it heals.
 ● SCARLET FEVER
● KAWASAKI
● STREPTOCOCCAL TOXIC SHOCK
SYNDROME
● STAPHYLOCCOCAL SCALDED SKIN
SYNDROME
CONFLUENT ● SJS

DESQUAMATIVE
SCARLET
FEVER
Diffuse blanchable erythema
beginning on face and spreading
to trunk and extremities;
circumoral pallor;
“sandpaper” texture to skin;
accentuation of linear erythema
in skin folds (Pastia’s lines);
enanthem of white evolving
into red “strawberry” tongue;
desquamation in second week
KAWASAKI
DISEASE
Rash similar to scarlet fever
(scarlatiniform) or EM; fissuring
of lips, strawberry tongue;
conjunctivitis; edema of hands,
feet; desquamation later in
disease
TOXIC SHOCK
SYNDROME
SJS

Erythematous and purpuric

macules, sometimes targetoid,
or diffuse erythema progressing
to bullae, with sloughing and
necrosis of entire epidermis;
Nikolsky’s sign;involvesmucosal
surfaces;
• TEN (>30% epidermal
necrosis) is maximal form;
• SJS involves <10% of
epidermis;
• SJS/TEN overlap involves
10–30% of epidermis
 ● VARICELLA
● HOT TUB FOLLICULITIS
● PRIMARY HERPES SIMPLEX

VESICULOBULLOU
S
 VARICELLA
Initially pink maculopapular lesions evolving into petechiae; petechiae
rapidly becoming numerous, sometimes enlarging and becoming
vesicular; trunk, extremities most commonly involved
 PRIMARY HERPES
SIMPLEX INFECTION
Erythema rapidly followed by hallmark painful grouped vesicles
that may evolve into pustules that ulcerate, especially on mucosal
surfaces; lesions at site of inoculation: commonly gingivostomatitis for
HSV-1 and genital lesions for HSV-2;
 HOT TUB
FOLLICULITIS
Pruritic erythematous follicular, papular, vesicular, or pustular
lesions that may involve axillae, buttocks, abdomen,
and especially areas occluded by bathing suits; can manifest as tender
isolated nodules on palmar or plantar surfaces
 ● ACUTE MENINGOCOCCEMIA
● DESSIMINATED GONOCCOCAL
FEVER

PURPURIC
LESIONS
 ACUTE
MENINGOCOCCEMIA
Initially pink maculopapular lesions evolving into petechiae; petechiae
rapidly becoming numerous, sometimes enlarging and becoming
vesicular; trunk, extremities most commonly involved; may appear on
face, hands, feet;
 DISSEMINATED
GONOCOCCAL
INFECTION
Papules (1–5 mm) evolving over 1–2 days into hemorrhagic pustules
with gray necrotic centers; hemorrhagic bullae occurring rarely; lesions
(usually <40) distributed peripherally near joints (more commonly on
upper extremities)
 ● ANTHRAX

ERUPTIONS WITH
ULCER/ ESCHAR
 ANTHRAX
Pruritic papule enlarging and evolving into a 1- by 3-cm painless ulcer
surrounded by vesicles and then developing a central eschar with edema;
residual scar
 03
FEVER OF
UNKNOWN
ORIGIN
FEVER OF
UNKNOWN
ORIGIN
FUO was originally defined by Petersdorf
and Beeson in 1961 as an illness of >3
weeks’ duration with fever of ≥38.3°C
(≥101°F) on two occasions and an
uncertain diagnosis despite 1 week of
inpatient evaluation.
01 Fever ≥38.3°C (≥101°F) on at least two occasions

02 Illness duration of ≥3 weeks

03 No known immunocompromised state

04 Diagnosis that remains uncertain after a thorough history-taking,

physical examination, and the following obligatory investigations:
ESR, CRP level; CBC + PLT, electrolytes, creatinine, total protein, ALK
PHOS, ALT, AST, LDH, creatine kinase, ferritin, antinuclear antibodies,
and rheumatoid factor; protein electrophoresis; UA; blood cultures;
urine culture; chest x-ray; abdominal UTZ; and tuberculin skin test or
interferon γ release assay.
 The most important step in the diagnostic workup is the
search for potentially diagnostic clues (PDCs) through complete and
repeated history-taking and physical examination and the obligatory
investigations listed above and in the figure.
The history should include:
• fever pattern (continuous or recurrent) and duration,
• previous medical history,
• present and recent drug use
• family history
• sexual history
• country of origin
• recent and remote travel
• unusual environmental exposures associated with travel, hobbies, and
animal contacts
THAN
KS

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