FEVER WITH RASH

PRESENTER –DR. SWAGATA SINHA, 1st year PGT, dept. of Medicine, AMCH

MODERATOR –DR. SRIMANTA MADHAB BARUAH, Professor ,Dept. of Medicine,

AMCH
 APPROACH TO FEVER WITH
RASH
• History –
1. Drug ingestion within past 60days like- sulfonamides, penicillin.
2. Travel outside the local area eg- rocky mountain spotted fever
3. Occupational exposure- healthcare worker, veterinary worker.
4. Immunisations- MMR vaccine.
5. Sexually transmitted disease exposure- syphilis.
6. Exposure to febrile or ill person within the recent past.
7. Exposure to sun, wild or rural habitats, insects , arthropods, wild animals, pets,outdoor water
source such as lakes, streams or ocean- Eg- SCRUB TYPHUS
8. Immunological drugs- chemotherapy, corticosteroid use, immune modulators, antibiotic allergies.
9. Season of the year- Spring season common for measles.
10. Prior drug history or antibiotic allergy history.
 PHYSICAL EXAMINATION
1. Vital signs
2. General appearance
3. Signs of toxicity
4. Presence and location of lymphadenopathy
5. Presence and morphology of genital, mucosal, or conjunctival lesions
6. Detection of hepatosplenomegaly
7. Presence of arthritis
8. Signs of nuchal rigidity,meningismus or neurologic dysfunction.
9. Presence of primary or secondary lesion and its pattern.
 Details about the rash
1. Site of onset
2. Rate and direction of spread
3. Presence or absence of pruritic
4. Temporal relationship of rash and fever
CENTRALLY DISTRIBUTED RASH-
VIRAL: Measles
Rubella
Erythema infectiosum
Erythema Subitum
Primary HIV infection
Dengue fever
Coxsakie viruses A9,B1,B5
Infectious mononucleosis
Exanthematous drug induced eruptions- Antibiotics, Anticonvulsants, diuretics.
BACTERIAL- Epidemic typhus
Endemic typhus
Scrub typhus
Rheumatic fever
Leptospirosis
Lyme disease
Typhoid fever
African trypanosomiasis

AUTOIMMUNE- SLE
Stills disease
PERIPHERALLY DISTRIBUTED
BACTERIAL- Rocky mounted spotted fever
Secondary syphilis
Bacterial endocarditis
VIRAL – Chikungunya fever
Hand foot and mouth disease
Erythema multiforme
LABORATORY TESTS
AND INVESTIGATIONS
• CBC
• ESR
• CRP
• Routine examination of urine
• LFT
• Blood and urine culture
• ICTC
Biopsy samples from - persistent purpuric lesions
• Inflammatory dermal nodules
• Ulcers
• Skin biopsy sample for IF staining
• Diagnosis of connective tissue disease is CLINICAL- supported by
SEROLOGY.
• SLE or Vasculitis- ANA, ANCA( by IFA and antiprotienase 3 and
Antimyeloperoxidase by ELISA.
Overview
 Maculopapular: Measles, rubella, dengue,etc

 Nodular: Erythema nodosum, Sweet’s syndrome,etc

 Purpuric: Meningococcemia, HSP, viral hemorrhagic fevers,etc

 Vesiculobullous: Varicella, herpes, SJS/TEN,etc

 Autoimmune Diseases: SLE,Dermatomyositis,Vasculitis,Still’s

disease,etc.
 Drug Reactions: DRESS,SJS/TEN, Serum Sickness-like Reaction,etc.
• PERPURIC ERUPTIONS
Bacterial
• Acute meningococcemia
• Chronic meningococcemia
• Purpura Fulminas
• Disseminated Gonococcal infection
• Therombotic Thrombcytopenic Purpura
• Hemolytic Uremic Syndrom
Viral
• Viral Hemorrhagic Fever
• Coxsackievirus A9
• Echovirus 9
• Epstein – Barr virus
• Cytomegalovirus
• VESICULOBULLOUS OR PUSTULAR ERUPTION
• Varicella
• Variola
• Primary Herpes infection
• Disseminated Herpers
• Rickettsial Pox
• Pseudomonas ‘’ hot tub’’ folliculitis
 MACULOPAPULAR RASH :MEASLES ( FIRST DISEASE
)
CAUSATIVE AGENT Paramyxovirus

HOST Common in children and Nonimmune

MODE OF SPREAD Droplet infection

ONSET Fever onset 2 to4 days before rash, rash occurs 3 to5 days of
fever.
RASH Macular-papular rash that may become confluent; begins on
face(at the hairline), neck and shoulders and spreads
centrifugally and inferiorly; fades in 4-6 days

CLINICAL FEATURES High grade fever with cough, coryza, conjunctivitis,

malaise,irritability. Koplik spots ( lower buccal mucosa) appears
2 days prior to rash
COMPLICATIONS Acute otitis media
Interstitial pneumonia
Myocarditis and pericarditis
Encephalitis
Subacute sclerosis panencephalitis ( SSPE )
Mesenteric lymphadenitis

DIAGNOSIS Clinical examination

IgM antibody detection
Viral RNA detection by RTPCR

TREATMENT Supportive
Adequate hydration
 RUBELLA ( GERMAN MEASLES, THIRD DISEASE)
CAUSATIVE AGENT Rubella virus ( ss RNA , Togavirus family)

HOST Young adult, nonimmune persons

MODE OF SPREAD Droplet infection

ONSET Fever 1 to 2days before rash, rash appears

2 to 3days after the fever starts.

RASH Pink macules and papules develop on

forehead spread to extremities, fades by
3rd day . Forchheimer’s sign in 20% cases
seen are small red papules on the areas of
soft palate.
 CLINICAL FEATURES
Low grade fever
Maculopapular rash
Suboccipital and posterior cervical lymphadenopathy
Joint pains
Headache and conjunctivitis
CONGENITAL RUBELLA SYNDROME DUE TO TRANSPLACENTAL
TRANSMISSION TO FETUS.

DIAGNOSIS- Rise in IgG antibody.

TREATMENT- Supportive care.
ERYTHEMA INFECTIOSUM( 5TH DISEASE)
CAUSATIVE AGENT Human parvovirus B19. Spreads by respiratory
secretions

ONSET Rash appears 2 to 5days after fever onset.

RASH Classic bright red facial rash( slapped cheek

appearance) and progress to lacy reticular rash,
may wax and wane for 6 to 8 weeks
CLINICAL FEATURES Mild fever, arthritis in adults
RASH after FEVER RESOLVES.

DIAGNOSIS Serology- B19V IgM antibodies detection

TREATMENT Supportive care

COMPLICATIONS DUE TO B19 VIRUS
• Polyarthropathy syndrome
• Transient Aplastic crisis
• Pure red cell aplasia / chronic anemia in immunosuppressed
• Hydrops fetalis in pregnant women.

Slapped cheek appearance

 INFECTIOUS MONONUCLEOSIS
CAUSATIVE AGENT Epstein barr virus

ONSET Fever lasts for several days, Rash can appear 1 to 2 weeks after
fever starts.

RASH Diffuse maculopapular rash .

Palatal petechiae

CLINICAL FEATURES Mostly asymptomatic

Fatigue and malaise
FEVER. PHARYNGITIS AND CERVICAL LYMPHADENOPATHY
Atypical lymphocytosis , hepatosplenomegaly

DIAGNOSIS Peripheral blood lymphocytosis with atypical lymphocytes

Elevated liver enzymes
Heterophyle antibody test- + monospot test or + paul bunnel
test.

TREATMENT No specific treatment . Steroids are indicated in severe cases.

Morbilliform rash
COMPLICATIONS
Neurological- meningitis, encephalitis, hemiplegia and gullain barre
syndrome and transverse myelitis.
Hemolytic anemia and thrombocytopenia
Upper airway obstruction from tonsillar hypertrophy
Myocarditis and pericarditis
Chronic fatigue
Cancers- non Hodgkin lymphoma.
Hepatits
Splenic rupture
pic
 PRIMARY HIV INFECTION
HOST Individual recently infectedwith HIV

CLINICAL FEATURE Fever

Persistent generalised lymphadenopathy
Skin rash
Pharyngitis
Myalgia and arthralgia
Gastrointestinal symtoms
Neurological symptoms like GBS, Pherpheral neuropathy

RASH 1 to 2 days of acute illness

Nonspecific diffuse macules and papules commonly
Urticarial or vesicular oral or genital ulcers
Desquamation of palms and soles
DIAGNOSIS P24 antigen detection
HIV RNA detection
pic
 EPIDEMIC TYPHUS ENDEMIC TYPHUS( murine)
CAUSATIVE AGENT Ricketssia prowazaki Ricketsssia typhi
HOST AND Regions affected by wars and disaster Exposure to cats or rats flea contaminated
ENVIRONMENT feces

VECTOR Human body louse Rat fleas

ONSET 4 TO 7days after fever begins 4 to 6 days after onset or may be absent

CLINICAL FEATURE Severe headache & sustained high fever Maculopapular rash starts on trunk sparing
with cough palms and soles. Less intense than
Maculopapular rash in axilla, spreading epidemic.
to trunk then extremities. SPARING Headache, myalgia, arthralgia
PALMS, SOLES &FACE. Interstitial pneumonia, pulmonary edema,
Photophobia, myalgia pleural effusion
Confusion and coma

DIAGNOSIS Serology serology

Detection of R.Prowazaki in a louse on a
patient
Flourescent ab test
TREATMENT Doxycycline 100 mg BD continues 2 to3 Doxycycline 100mg BD
days after defervescnce Ciprofloxacin
SYPHILIS
Key Features of Secondary Syphilis
• Fever:
Low-grade fever is common, along with malaise and other constitutional symptoms.
• Rash: ONSET- typically 6 to 12 weeks after initial infection.
• Generalized, symmetric, non-itchy maculopapular rash
• Involves palms and soles – a hallmark feature
• May also be papular, pustular, or scaly
• Rash may resolve spontaneously within weeks
• Other Associated Signs:
• Generalized lymphadenopathy
• Condylomata lata (moist, warty lesions in genital/perianal area)
• Mucous patches in the mouth
• Alopecia (moth-eaten appearance)
Diagnosis:
• Serologic tests:
• Non-treponemal (e.g., VDRL, RPR) – for screening
• Treponemal (e.g., FTA-ABS, TPHA) – for confirmation
Treatment:
• Single dose of benzathine penicillin G 2.4 million units IM
• Follow-up with serologic titers
 SCRUB TYPHUS
CAUSATIVE AGENT Orientia tsutsugamushi

ONSET 5 TO 7days after fever onset but not always.

VECTOR Trombiculid mite

INCUBATION PERIOD 6 to 21 days

CLINICAL FEATURE Fever , diffuse maculopapular rash, starting on trunk

Eschar at the site of mite bite
Regional lymphadenopathy, headache

COMPLICATIONS Pneumonitis, encephalitis, myocardtitis , AKI, transamitis

DIAGNOSIS Eschar is diagnostic
Weil felix test
Indirect immunofluorescence

TREATMENT Doxycycline 100mg BD oral 7 to 15 days

Azithromycin 500mg OD oral 3days
Chloramphenicol 500mg qid oral 7 to 15days
pic
 ROCKY MOUNTAIN SPOTTED FEVER
CAUSATIVE AGENT Ricketssia rickettsii

HOST AND ENVIRONMENT Young adult with tick exposure

VECTOR Tick

ONSET 2 TO 5 days after fever begins

RASH Rash eveolving from pink macule to red papulesand

finally to petechiae. Beginning from wrist and ankle to
centripetally
Involvement of palms and soles late in disease.
Fever, headache, myalgia, conjunctival suffusion with
periorbital edema
Cardiac involvement
Meningoencephalitis
Respiratory failure
DIAGNOSIS Thrombocytopenia with normal WBC COUNT
and petechial rash
Weil felix test
Indirect immunofluorescence assay

TREATMENT Doxycycline 100mg BD continues 2 to 3days after

defervescence.
ROCKY MOUNTED SPOTTED FEVER
 DENGUE FEVER
CAUSE Dengue virus

VECTOR Female aedes mosquito

CLINICAL FEATURE FEBRILE PHASE- Sudden onset fever with vomiting and diarhoea, myalgia, gum
bleeding and epistaxix with maculopapular rash
Rash often appears 3 to 4days after fever.

CRITICAL PHASE- Hypotension and shock, pleural effusion and ascites, bledding GI
Metabolic acidosis, organ impairement

RECOVERY PHASE- pruritis and bradycardia

RASH Diffuse flushing with maculopapular rash begins
on trunk and spreads to extremities and face
Petechiae on extremities
Pruritis during recovery

SEVERE DENGUE 1. Plasma leakage

2. Severe bleeding
3. Severe organ impairement

DIAGNOSIS Virus detection RTPCR

NS1 Ag
Serology

TREATMNENT Supportive
Adequate hydration
Blood transfusion
Management of complications
pic
 TYPHOID FEVER
CAUSATIVE AGENT Salmonella typhi

MODE OF TRANSMISSION Ingestion of contaminated food and water

ONSET Fever starts gradually . Rash 7 to 10days after fever

CLINICAL FEATURE Prolonged high fever upto 4weeks

Relative bradycardia
Rash appears on 1st week
Arthralgia and myalgia
GI symptoms- Anorexia, constipation, diarrhoea
Splenomegaly
Hepatitis

RASH Rose spots seen on chest and abdomen in 1st week

Small pale red macules blanchable
Lasts 2 to 3days
COMPLICATIONS GI bleeding and perforation
Meningitis, gbs, peripheral neuritis, delirium
Circulatory collapse, DIC
Osteomyelitis, endocardtitis, pyelonrphritis,
glomerulonephritis
Hepatic and splenic abscess

DIAGNOSIS Leucopenia
Raised liver enzymes
Blood culture
Widal test
Typhi dot IgM
PCR

TREATMENT Supportive care

Antibiotics – ceftriaxone, azithromycin, cefixime.
pic
CAUSE
LEPTOSPIROSIS
Leptospira interrogans

HOST Exposure to water contamination

ONSET Rash appears early within first 4 to 7days of illness. Rash typically transient –
MACULOPAPULAR RASH .

CLINICAL FEATURES 1st PHASE- High grade fever with severe headache and myalgia
(ACUTE) conjunctival suffusion, abdominal pain
maculopapular rash
2 PHASE- Meningits
nd

(IMMUNE) iridocyclitis

SEVERE LEPTOSPIROSIS( WEIL’S SYNDROME)- Intense jaundice

Renal failure and hypotension
Hemorrhage- pulmonary, gi, ich, pulmonary.
Purpuric rash
DIAGNOSIS Elevated ESR, Neutrophilia
Elevated bilirubin and liver enzymes
Isolation of organism
Culture from blood , csf, urine
PCR
Serology- microscopic agglutination test

TREATMENT Doxycycline 100mg bd tab or Amoxycillin 500mg tabs tds in mild cases

Doxycycline 250mg od tab once a week

Or
Azithromycin 250 mg once or twice a week.
pic
CHIKUNGUNYA FEVER
Csuse Chikungunya virus

Vector Aedes aegtpti and Aedes albopictus

Incubation period 2 to 4 days

Clinical Features Acute stage – sudden onset high fever, incapacitating polyarthritis
Maculopapular rash(20-50%), Conjunctivitis
Long- lasting disabling polyarthritis
Severe polyarticular migratory arthralgias mainly involving small joints
Axial involvement
Chronic Rheumatism is common(weeks to more than 1 year)

Rash Transient (between day 1- 4) after fever onset. Often blanching.

Pruriginous maculopapular rash mostly on face , trunk, and extremities.
Hyperpigmentation during healing phase.
Diagnosis Serology(lgm for CHIKV)
RT-PCR
Virus islation

Treatment Supportive
 Bacterial Endocarditis
Cause Staphylococcus
Streptococcus

Host Prosthetic Heart Valve

Abnormal Heart Valve
Intravenous Drug Users

Clinical Features Vague Symptoms

High Grade or Low Grade Fever
Splenomegaly
CVS- Appearance of new murmur
Change in Character of an exsting murmur
Worsening of cardiac failure
Rash Petechiae, small pinpoint red or purple spots on skin or
mucous membrane.

Janeway Lesions Painless Erythematous macules usually on palms and soles

Osler Nodes Tender pink nodules on finger or toe pads

Petechail Rash on skin and Mucosa

Splinter Haemorrhages on Nails

Erythema Marginatum(Rheumatic Fever)
Cause Group A Streptococcus

Host Patients with rheumatic Fever

Rash Erythematous annular papules and plaques over

Trunk and proximal extremeties
Evanescent(evolving and resolving within hours)
Blanches with pressure, it is migratory.
Occurs early in course of disease.

Clinical Features Fever, polyarthralgia

Elevated ESR
Carditis, Polyarthritis , chorea , Erythema
Marginatum
Subcutaneous nodules

Diagnosis Revised jones Criteria

NODULAR ERUPTIONS

• Disseminated Fungal Infection

• Erythema Nodusm
• Sweet’S Syndrome
ERYTHEMA NODUSUM
Cause Infectious cause – Streptococcal pharyngitis (most common)
-Tuberculosis (TB)
-Yersinia enterocolitica
-Chlamydia
-Histoplasmosis
Inflammatory and Autoimmune Diseases-Sarcoidosis
-Inflammatory Bowel Disease (IBD)
-Crohn's disease, Ulcerative colitis
-Behçet’s disease
Drug Reactions-Sulfonamides
-Oral contraceptive pills (OCPs)
-Penicillin
-NSAIDs
Pathogenesis Delayed hypersensitivity
Immune Complex Mediated
Clinical Featues Fever, weakness and arthralgia.
Tender red nodules on extensor surfaces
Rash Large , violaceous, nonulcerative , tender, subcutaneous
Nodules , 1 to 5cm in size. Symmetrical occurs in both legs.
After initial trigger the nodules appears around 7 to 21 days later.

Diagnosis Clinically

Treatment Self Limiting , resolves in 3-6 weeks

NSAIDS
Treat the cause
SWEET Syndrome
(acte febrile neutrophilic dermatosis)
SS is a reactive phenomenon and considered a cutaneous marker of systemic disease
More common among women and among persons 30-60 years old

Cause Idiopathic ( Classic)

Malignancy- Hematological

Yersinial infection

Drug Induced

Pregnancy

Inflammatory Bowel Disease

Presentation Sudden onset of fever
An elevated white blood cell count
Arthralgia or arthritis
Eye involvement – conjunctivitis or iridocyclitis

RASH Acute, tender , erythematous plaques , nodes, pseudovesicles and , occasionally

Blisters with an annular of arciform pattern occur on the head, neck legs and
Arms.

Lesion show dense infilteates by neutrophil granulocytes on histologic

examination

Diagnosis Diagnosis of exclusion

Neutrophilia
Elevated ESR
Skin biopsy
Treatment Systemic corticosteroids(prednisone)
PURPURIC ERUPTION
Bacterial
• Acute meningococcemia
• Chronic meningococcemia
• Purpura Fulminas
• Disseminated Gonococcal infection
• Therombotic Thrombcytopenic Purpura
• Hemolytic Uremic Syndrom
Viral
• Viral Hemorrhagic Fever
• Coxsackievirus A9
• Echovirus 9
• Epstein – Barr virus
• Cytomegalovirus
 MENINGOCOCCAL INFECTIONS
Causative Agent Neissseria meningitidis

Host and Environment Children ,

Asplenic Indiciduals
Terminal Complement component
Deficiency(C5-C8)

Transmission Close contact by respiratory droplest or

Secretions
Asymptomatic carriers

Pathogenesis Colonization of URT---- penetrate into

Bloodstream--- Go to CNS causing meningitis
(meningitis)/
Infect the blood vessel ( meningococcemia)
 Clinical
Features
Acute lllness High Fever , Tachycardia
Tachypnea
Hypotension
Rash Erythematous maculopapular rash initially 1 TO 2 days after fever.
Petechial or frankly purpuric over hours
Large purpuric lesions in severe cases (purpura Fulminans)
Meningitis Fever , irrtabiloty and vomiting
Neck Stiffness, photophobia, altered sensorium, seizures
Septicemia High Mortality
Shock
Multiorgan Failure
Disseminated intravascular Coagulation
Purpura Fulminans(large purpuric lesions and peripheral ischemia)

Meningococcal Multilobar , rapidly evolving pneumonia

pneumonia
DISSEMINATED GONOCCAL
INFECTION
Causative Agent Neisseria gonorrhoeae ( Resistant DGI strains)

Clinical Features Low grade Fever to high grade Fever

Skin Lesions
Tenosynovitis and suppurative Arthritis
Genitals lesions usually not be present
Rash Usually appears within days to weeks after dissemination .
Typically 10 to 20 in number.
Papules or petechiae evolving rapidly to hemorrhagic
Pustules , with grey necrotic center
Papules,pustule, and hemorrhagic lesions all
May be present simultaneously

Diagnosis Blood culture

Synovial fluid Culture

Treatment Inj Ceftriaxone 1 g IV q24 h

VIRAL HEMORRHAGIC FEVER
Case Ebola virus and Marburg virus,
Lassa Fever , Lujo Virus , south American
Hemorrhagic
Fever
Dengue , Yellow Fever , kyasanur Forest disease
Clinical Features Early stage- Red macule or tiny petechiae. Can
progress to purpura, ecchymoses. Rash often appears
on trunk, limbs, and face sometimes. Severe cases
bleeding may occur.
Rash often appears around the time of fever peak or
slightly after often 3 to 6days into illness.
DIAGNOSIS Thrombocytopenia, leukopenia or leucocytosis, PT,
APTT, D- Dimer.
PCR.
VESICULOBULLOUS OR PUSTULAR ERUPTION

• Varicella
• Variola
• Primary Herpes infection
• Disseminated Herpers
• Rickettsial Pox
• Pseudomonas ‘’ hot tub’’ folliculitis
Varicella
Cause Varicella Zoster Virus
Host Commonly in children

Mode of transmission Droplet infection or Discharge by ruptured lesions

ONSET 1 TO2 days after fever onset.

Clinical Features Low Grade Fever

Rash Appears on Trunk on 2nd day of illness, spreads to
Face , and limbs
Rash Macules(2-3mm) evolving to papules , then vesicles on a
Erythematous base (‘’ dew drops on a rose petal’’)
Pustules and then Crusting
Lesions appear in crops
Intensely pruritic
Hemorrhagic lesion in immunocompromissed
Complications Heroes Zoster(reactivation of latent infection
Myocarditis
Hepatitis
Interstitial Pneumonitis
Meningitis
Acute glomerulonephritis

Herpes Zoster Unilateral Vesicular Dermatomal eruption associated

With severe pain
Rash appears 3 to 5days after onset of nerve pain
Headache , fever and malaise
Complication are Common

Dianosis Clinical
Tzanck Smear of vesicular fluid shows inclusion bodies
Lsolation of virus
PCR

Treatment Supportive
Acyclovir
Primary Herpes infection
Causative Agent Herpes simplex virus 1 (HSV-1)and type 2 (HSV-2)

LOCATION HSV-1- Mouth and lips

HSV -2- mainly genitalia
Grouped vescicles on a red base. Painful and itchy, Rupture to form
shallow ulcer.
TIMELINE Prodrome lasts about 1 to 2days, vescicles appear and cluster within
24 to 48hrs. Rupture and ulceration over next several days.
Healing in 10 to 14days without SCARS.
Clinical Conditions Herpetic gingivostomatitis
Herpes labialis
Herpes genitalis
Herpes Encephalitis
Herpes Oesophagitis
Herpes Labialis Small blisters or cold sores on or around the mouth
Fever
Recurrence is common
Sores heal within 2-3 weeks but virus remains dormant in the facial
Nerves
Severe pharyngitis with dysphagia
Lymphadenopathy

Herpetic Gingvostomatitis Similar to herpes labialis with greater sevrity

Herpes Genitalis Clusters of genital sores consisting of inflamed papules and vesicles
on
The outer surface of the genitals

Dianosis Clinical
Culture of the virus
Direct fluorecent anti body
Skin biopsy
PCR

Treatment Self – limiting

Antivirals
AUTOIMMUNE – SYSTEMIC LUPUS ERYTHEMATOSUS.
• MALAR RASH- BUTTERFLY RASH- Symmetric , erythematosus, flat or
slightly raised.
• Covers cheeks and bridge of nose. SPARING NASOLABIAL FOLD.
• May be scaly
• Non pruritic
• Can worsen with sun exposure.
• OTHER FINDING- DLE RASH( round, scaly, atrophic plaque)
oral ulcers
alopecia.
• SLE RASH WITH FEVER- LUPUS FLARE ( Rash may worsen ,
widespread, and associated joint pain, fatigue, serositis.)
• Subacute Cutaneous lupus erythematosus- Annular or psoriasiform
rash, photosensitive with FEVER.
• Infection- fever in SLE is often caused by infection due to
immunosuppression.
 Vasculitis Causing Fever and
Rash:
Vasculitis Type Vessel Size Key Rash Other Features
Henoch-Schönlein Purpura (IgA Palpable purpura on Arthritis, GI bleeding,
Small
vasculitis) legs/buttocks renal involvement
Glomerulonephritis,
Microscopic Polyangiitis (MPA) Small Palpable purpura
pulmonary hemorrhage
Granulomatosis with polyangiitis Upper/lower airway +
Small–medium Purpura, ulceration
(GPA) renal involvement
Asthma, eosinophilia,
Eosinophilic GPA (Churg-Strauss) Small–medium Purpura, urticaria
neuropathy

Mononeuritis multiplex,
Livedo reticularis,
Polyarteritis Nodosa (PAN) Medium renal/abdominal
nodules
involvement

Mucosal changes,
Kawasaki Disease Medium Polymorphous rash conjunctivitis,
desquamation

Maculopapular rash,
Hypersensitivity Vasculitis Small Usually drug-induced
purpura
Henoch-Schönlein Purpura (IgA vasculitis)

Kawasaki Disease
STILL’ S DISEASE
Systemic – onset juvenile idiopathic Adult – onset Still ‘ s disease
arthritis

Fever Arthritis
Migrating Rash Fever
Hepatosplenomegaly Salmon colored evanescent rash
Lymphadenopathy Elevated Serum Ferritin
Arthritis
DERMATOMYOSITIS

Fever
• Usually low to moderate grade
• May precede or accompany muscle weakness and rash
• Suggests systemic inflammation or possibly associated malignancy or
infection
Rash Description

Heliotrope Rash Violaceous rash with periorbital edema (eyelids)

Scaly, violaceous papules over knuckles (MCP, PIP

Gottron’s Papules
joints)

Erythema over extensor surfaces (elbows, knees,

Gottron’s Sign
etc.)

Photosensitive rash on upper back, shoulders (shawl)

Shawl Sign / V Sign
or anterior chest (V)

Photosensitive Rash Often aggravated by sunlight exposure

Drugs causing Fever with Rash
Drug Class Examples Possible Rash Type

Morbilliform (maculopapular), urticaria,

Antibiotics Penicillins, Sulfonamides, Cephalosporins
SJS/TEN

Vancomycin Red man syndrome (infusion-related)

Anticonvulsants Phenytoin, Carbamazepine, Lamotrigine DRESS, SJS/TEN, morbilliform

NSAIDs Ibuprofen, Naproxen Urticaria, DRESS, fixed drug eruption

Allopurinol — DRESS, SJS/TEN

Antiretrovirals Abacavir, Nevirapine Hypersensitivity syndrome, SJS
Anti-TB drugs Isoniazid, Rifampin Morbilliform, urticaria

Biologics Monoclonal antibodies (e.g., infliximab) Serum sickness-like reactions

Chemotherapeutic agents Cytarabine, Methotrexate Various, including toxic erythema

Mild rash and fever as part of immune

Vaccines MMR, Varicella, others
response
Serious Drug Reactions Causing Fever + Rash:
DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms)
•Rash + fever + eosinophilia + organ involvement
•Common drugs: Allopurinol, phenytoin, carbamazepine

SJS/TEN (Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis)

•Severe mucocutaneous necrosis
•Common drugs: Sulfonamides, anticonvulsants, allopurinol

Serum Sickness-like Reaction

•Fever, rash, arthralgia
•Common with β-lactams, monoclonal antibodie
References:
• Harrison's Principles of Internal Medicine,21st Edition
• API Textbook of Medicine
• Hutchison's Clinical Methods: An Integrated
Approach to Clinical Practice
Thank
you