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FEVER AND RASH. Prof. H. Herry Garna, dr., Sp.A(K), Ph.D. Infection – Tropical Disease Subdivision Department of Child Health, Faculty of Medicine Padjadjaran University, Hasan Sadikin General Hospital Bandung. Introduction. - PowerPoint PPT Presentation
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Prof. H. Herry Garna, dr., Sp.A(K), Ph.D
Infection – Tropical Disease SubdivisionInfection – Tropical Disease Subdivision
Department of Child Health, Faculty of MedicineDepartment of Child Health, Faculty of Medicine
Padjadjaran University, Hasan Sadikin General Hospital Padjadjaran University, Hasan Sadikin General Hospital BandungBandung
FEVER AND RASH
IntroductionIntroduction
Fever is often the first symptom noted by Fever is often the first symptom noted by parents, common problem in clinicparents, common problem in clinic
Wide range of severity: Wide range of severity:
self limiting disease self limiting disease life-threatening life-threatening Wrong first suspicion Wrong first suspicion fatal outcome fatal outcome It is more likely to be caused by infection, It is more likely to be caused by infection,
but any inflammatory, neoplastic, but any inflammatory, neoplastic, immunologic or traumatic event can immunologic or traumatic event can generate fevergenerate fever
IntroductionIntroduction
Knowledge of differential diagnosis is Knowledge of differential diagnosis is very importantvery important
DiagnosisDiagnosis
- Accurate anamnesis- Accurate anamnesis
-- Physical examination Physical examination
- Supporting examination- Supporting examination
Differential DiagnosisDifferential Diagnosis
Past history of infectious disease and Past history of infectious disease and immunizationimmunization
Type of prodromal periodType of prodromal period Feature of the rashFeature of the rash Presence of pathognomonic or other Presence of pathognomonic or other
diagnostic signsdiagnostic signs Laboratory diagnostic testsLaboratory diagnostic tests
Differential DiagnosisDifferential Diagnosis
Feature of the rashFeature of the rash
* * Category:Category:
- Macular or maculo-papular:- Macular or maculo-papular:
Morbilli, rubella, roseola infantum, Morbilli, rubella, roseola infantum,
scarlatinascarlatina
- Papulo-vesicular:- Papulo-vesicular:
Varicella, herpes zoster, variolaVaricella, herpes zoster, variola
* * Character: Character: discrete or confluentdiscrete or confluent
* Distribution, duration* Distribution, duration
* * The appearance associated with fever?The appearance associated with fever?
Etiologic AgentsEtiologic Agents
Infectious DiseasesInfectious Diseases VirusVirus
Classic viral exanthema: Classic viral exanthema:
Measles, Rubella, Varicella Zoster Virus Measles, Rubella, Varicella Zoster Virus (VZV)(VZV)
Parvovirus, Roseola (HHV 6 and HHV 7) Parvovirus, Roseola (HHV 6 and HHV 7)
Others: HSV, EBV, HBV, Enterovirus, Others: HSV, EBV, HBV, Enterovirus, DengueDengue
BacteriaBacteria
Scarlet fever, Scarlet fever, mmeningococcemia, typhoid fevereningococcemia, typhoid fever
Staphylococcal infection (sepsis, toxic shock Staphylococcal infection (sepsis, toxic shock syndrome)syndrome)
Etiologic AgentsEtiologic Agents
MycoplasmaMycoplasma Rickettsia Rickettsia
Noninfectious DiseasesNoninfectious Diseases AllergicAllergic: food, drugs, toxin, serum : food, drugs, toxin, serum
sicknesssickness
The etiology remains elusiveThe etiology remains elusive: : Kawasaki Kawasaki diseasedisease
AnamnesisAnamnesis
Demographic dataDemographic data Appearance of rashAppearance of rash History of exposureHistory of exposure History of health beforeHistory of health before History of disease in the familyHistory of disease in the family Other complaintOther complaint
AnamnesisAnamnesis
Demographic DataDemographic Data
Age: neonate, infant, older childrenAge: neonate, infant, older children Sex Sex EthnicEthnic//race : Kawasaki disease ?race : Kawasaki disease ? Season: winter or dry season or not Season: winter or dry season or not
specificspecific Certain geographic: endemicCertain geographic: endemic
AnamnesisAnamnesis
Appearance of rashAppearance of rash
Location and distributionLocation and distribution Expansion and evolutionExpansion and evolution Correlation between rash and feverCorrelation between rash and fever
in the period of high fever (morbilli)in the period of high fever (morbilli)
in the period of decreasing fever in the period of decreasing fever (roseola infantum) (roseola infantum)
Pain or itching (drug eruptiPain or itching (drug eruptioon: itching) n: itching)
AnamnesisAnamnesis
History of ExposureHistory of Exposure
Contac t with similar disease (house, Contac t with similar disease (house, others)others)
TravelTravel Pet, insectsPet, insects Medicine or other medical measuresMedicine or other medical measures ImmunizationImmunization
AnamnesisAnamnesis
History of health beforeHistory of health before
History of disease beforeHistory of disease before Growth and developmentGrowth and development History of recurrent diseaseHistory of recurrent disease
History of disease in the familyHistory of disease in the family
Autoimmun ?Autoimmun ?
AnamnesisAnamnesis
Other complaintOther complaint
Local complaint (specific organ) Local complaint (specific organ)
Systemic complaint Systemic complaint (multiorgan/multisystem diseases)(multiorgan/multisystem diseases)
Physical ExaminationPhysical Examination
General condition/severity of diseaseGeneral condition/severity of disease
Characteristic of rashCharacteristic of rash
With enanthemWith enanthemaa
Other physical disordersOther physical disorders
Physical ExaminationPhysical Examination
General condition/severity of diseaseGeneral condition/severity of disease Meningococcemia, Staphylococcal Meningococcemia, Staphylococcal t toxic oxic
syndromesyndrome
Characteristic of rashCharacteristic of rash
Macule, Macule, ppapule, apule, mmaculo-papuleaculo-papule Vesicle, Vesicle, ppustule, ustule, bbullaulla PetechiPetechiaae or purpurae or purpura Erythroderma: diffuse or localErythroderma: diffuse or local
Nonblanching lesionsNonblanching lesions
PPetechietechiaae, purpura, and echymosise, purpura, and echymosis Difference sizeDifference size PetechiPetechiaae diameter <2 mm e diameter <2 mm PPurpura 2 mm–1 cmurpura 2 mm–1 cm EEchymosis diameter >1 cmchymosis diameter >1 cm
Physical ExaminationPhysical Examination
With enanthemWith enanthemaa Mouth: Hand-foot-mouth disease?Mouth: Hand-foot-mouth disease?
Buccal mucosa, Buccal mucosa, ppalatum, pharyngalatum, pharyng,, and and tonsiltonsil
Genital mucosaGenital mucosa
OthersOthers Arthritis, eye disorders, cardiac disordersArthritis, eye disorders, cardiac disorders Hepatomegaly, splenomegaly, Hepatomegaly, splenomegaly,
lymphadenopathylymphadenopathy
Diffential Diagnosis of Fever Diffential Diagnosis of Fever and Rashand Rash
Viruses Bacteria Other
Maculo/papular Measles, rubella, HHV-6, DengueEBV, HBV, HIV, enterovirus
GABHS(scarlet fever)Salmonella, Lyme,Mycoplasma pneumoniae
Rickettsia
Vesicular, bullous
VZV, HSV, EchovirusCoxsackievirus A, B(HFMD)
Impetigo (GAS)
Petechiae Hemorrhagic fever, CMV, EBV, VZVenterovirus
Sepsis (N.men, S.pneu,Hib)Rat bite fever
Rickettsia
Diffuse erythroderma
Dengue GABHS (scarlet fever)TSS
C. albicans
Morbilli (Measles, Rubeola)Morbilli (Measles, Rubeola)
Clinical AppearanceClinical Appearance Incubation period: 10–12 daysIncubation period: 10–12 days Three stadia: prodromal—eruption— convalescentsThree stadia: prodromal—eruption— convalescents ProdromalProdromal: 3–5 days: 3–5 days
3 C3 C ( (Coryza, Conjunctivitis, CoughCoryza, Conjunctivitis, Cough), fever, ), fever, Koplick’s spotsKoplick’s spots
EruptionEruption: high fever (40–40,5°C) : high fever (40–40,5°C) Typical rash: Typical rash:
- Maculo-papular- Maculo-papular erythromatouserythromatous
- Confluence-general- Confluence-general
- Start from backside of ear (head) - Start from backside of ear (head) body and body and upper arm upper arm lower extremities during 3 days lower extremities during 3 days whole of bodywhole of body
MorbilliMorbilli
Endemic in developing countriesEndemic in developing countries Effective immunization programEffective immunization program
cases decreasingcases decreasing
prone to older age groupprone to older age group• Lesion particularly at skin, mucous Lesion particularly at skin, mucous
membrane, conjunctivamembrane, conjunctiva• Serous exudate, mononuclear cell Serous exudate, mononuclear cell
predominantpredominant
DiagnosisDiagnosis
AnamnesisAnamnesis
* Symptoms* Symptoms
* History: contact, immunization* History: contact, immunization Clinical signsClinical signs
* Typical* Typical Laboratory examinationLaboratory examination
* Leukopenia* Leukopenia
* Relative lymphocytosis* Relative lymphocytosis
Clinical Manifestations of Clinical Manifestations of MorbilliMorbilli
Koplick’s spots Conjunctivi
tis
Rash distribution from head to lower extremities
Measles
MorbilliMorbilli
ComplicationsComplications Acute otitis media (10–15%)Acute otitis media (10–15%) Pneumonia interstitialis (50–75% with radiologic Pneumonia interstitialis (50–75% with radiologic
abnormalities) abnormalities) Myocarditis and pericarditisMyocarditis and pericarditis Encephalitis (1/1,000 cases) 7–10 days after rash Encephalitis (1/1,000 cases) 7–10 days after rash
appearance appearance
(1/3 dead, 1/3 physical defect, 1/3 recover )(1/3 dead, 1/3 physical defect, 1/3 recover ) Subacute sclerosing panencephalitis (SSPE)Subacute sclerosing panencephalitis (SSPE)
(0(0,,2–2 /100,000 morbilli, mean2–2 /100,000 morbilli, mean incubation 7 years)incubation 7 years)
CFR almost 100% after 6–9 monthsCFR almost 100% after 6–9 months
ComplicationsComplications
Persistent diarrheaPersistent diarrhea Exaserbation of tuberculosis (TBC)Exaserbation of tuberculosis (TBC) Keratoconjunctivitis Keratoconjunctivitis blindness blindness Secondary bacterial infection of skinSecondary bacterial infection of skin NomaNoma
Rubella (German Measles)Rubella (German Measles)
Clinical ManifestationsClinical Manifestations
Incubation period: 15—21 daysIncubation period: 15—21 days Mild prodromal sign:Mild prodromal sign:
- mild fever- mild fever
- adolescent: more severe- adolescent: more severe Rash: maculopapularRash: maculopapular
face face centrifugal to neck centrifugal to neck trunk, trunk, extremities extremities 24 hours all of body 24 hours all of body resolve in 3resolve in 3rdrd day day
Congenital Rubella Congenital Rubella SyndromeSyndrome
Depend on gestational ageDepend on gestational age
AbortusAbortus
StillbirthStillbirth
Congenital anomalyCongenital anomaly GravidaGravida
1–4 weeks: 61%1–4 weeks: 61%
5–8 weeks: 26%5–8 weeks: 26%
9–12 weeks: 8%9–12 weeks: 8%
Congenital Rubella Congenital Rubella SyndromeSyndrome
Opthalmologic: Cataract - Opthalmologic: Cataract - MicropthalmiaMicropthalmia
Glaucoma - Glaucoma - ChorioretinitisChorioretinitis
Cardiac: Septal defect - PDACardiac: Septal defect - PDA Neurologic: Meningoencephalitis Neurologic: Meningoencephalitis
Microcephaly Microcephaly
Mental retardation Mental retardation Auditoric: Sensorineural deafnessAuditoric: Sensorineural deafness
Exanthema Subitum Exanthema Subitum (Roseola Infantum)(Roseola Infantum)
Acute infection caused by human herpes Acute infection caused by human herpes virus 6 (some HHV 7)virus 6 (some HHV 7)
Mostly in infantMostly in infant Sporadic (sometimes epidemic)Sporadic (sometimes epidemic) Typical feature:Typical feature:
- Severity of clinical sign unproportionally- Severity of clinical sign unproportionally
with degree of feverwith degree of fever
- Simultaniously resolve of rash and - Simultaniously resolve of rash and clinical signclinical sign
Clinical ManifestationClinical Manifestation
Incubation period: 7–17 days (mean 10 days)Incubation period: 7–17 days (mean 10 days) Most common in 6–18 months oldMost common in 6–18 months old FeverFever
- abruptly high: 39,4–41,2°C- abruptly high: 39,4–41,2°C
- duration: 1–5 days (mostly 3–4 days)- duration: 1–5 days (mostly 3–4 days)
- convulsion can occur- convulsion can occur Mild clinical sign: mild pharyngitis and coryzaMild clinical sign: mild pharyngitis and coryza Rash: not specific: macule/maculopapular, rose color Rash: not specific: macule/maculopapular, rose color
chest chest extremities and neck extremities and neck face face Appear while temperature has return to normalAppear while temperature has return to normal Disappear on 1–2 days with normal skinDisappear on 1–2 days with normal skin
PrognosisPrognosis
Particularly good prognosisParticularly good prognosis Bad prognosis:Bad prognosis:
Hyperpyrexia with persistent Hyperpyrexia with persistent convulsionconvulsion
Scarlet Fever - ScarlatinaScarlet Fever - Scarlatina
Clinical manifestationClinical manifestation Incubation period: 1–7 days (mean: 3 Incubation period: 1–7 days (mean: 3
days)days) Acute symptoms: high fever—Acute symptoms: high fever—
headache— vomiting—chillsheadache— vomiting—chills Signs: severe pharyngitis Signs: severe pharyngitis
hyperemia— edema— exudate—hyperemia— edema— exudate—dysphagiadysphagia
Sometimes abdominal painSometimes abdominal pain Enlargement of lymph nodeEnlargement of lymph node
SScarlet Fevercarlet Fever - Scarlatina- Scarlatina
Typical rashTypical rash Erythroderma diffuse (red sandpaper)Erythroderma diffuse (red sandpaper) Reddish macule/papule Reddish macule/papule blanching on pressure blanching on pressure Firstly on axilla, groin, and neck Firstly on axilla, groin, and neck 24 hours all of 24 hours all of
bodybody Petechiae can occurPetechiae can occur Rash at chin and forehead (confluence): Rash at chin and forehead (confluence):
circumoral palorcircumoral palor Usually: Usually: palms and soles of feetpalms and soles of feet
Scarlet FeverScarlet Fever - Scarlatina- Scarlatina
Tongue: white thick membrane Tongue: white thick membrane
(white strawberry tongue)(white strawberry tongue)
After several days : peeled off After several days : peeled off papule papule (red strawberry tongue)(red strawberry tongue)
Pintpoint petechiae in the flexures Pintpoint petechiae in the flexures
produce a linear purpuric pattern produce a linear purpuric pattern
(pathognomonic)(pathognomonic)(Pastia’s lines)(Pastia’s lines)
Scarlet Fever (Scarlatina)Scarlet Fever (Scarlatina)
A beta-hemolytic Streptococcus group A beta-hemolytic Streptococcus group pyrogenic toxin (erythrogenic toxin)pyrogenic toxin (erythrogenic toxin)
Desquamation occur from end of 1Desquamation occur from end of 1stst week to week to 66thth week of disease week of disease
Diagnosis: History and physical examinationDiagnosis: History and physical examination
Pharyngeal swab: bacterial culturePharyngeal swab: bacterial culture
Serologic: ASTO/ASLO/ASOSerologic: ASTO/ASLO/ASO
Complete blood count: leukocytosisComplete blood count: leukocytosis
CRP increased or +: not specificCRP increased or +: not specific
Scarlet FeverScarlet Fever - Scarlatina- Scarlatina
Desquamation of rash after 1 week, Desquamation of rash after 1 week,
especially in hand and footespecially in hand and foot
ComplicationsComplications
Local spread/per continuitatum:Local spread/per continuitatum:
- Sinusitis – otitis media – mastoiditis- Sinusitis – otitis media – mastoiditis
- Retro/parapharyngeal abcess- Retro/parapharyngeal abcess
- Brochopneumonia- Brochopneumonia
- Servical adenitis- Servical adenitis Hematogenic spreadHematogenic spread - Meningitis – osteomyelitis – arthritis (septic)- Meningitis – osteomyelitis – arthritis (septic) Non suppurative (late) complicationsNon suppurative (late) complications
- Acute rheumatic fever- Acute rheumatic fever
- Acute- Acute glomerulonephritisglomerulonephritis
• Incubation period: 3–14 days
• Fever: suddenly high disappear: day-3 or 4 recover or dicrease: day-3 atau 4 , and appear again after 1–3 days camel saddle Long of fever: 5–7 days
• Incubation period: 3–14 days
• Fever: suddenly high disappear: day-3 or 4 recover or dicrease: day-3 atau 4 , and appear again after 1–3 days camel saddle Long of fever: 5–7 days
Dengue Fever (1)Dengue Fever (1)
Other complaint
• Headache, retro orbital pain
• Joint pain, back pain (backborne fever)
• Weakness, malaise
• Flushing: face, neck
• Photophobia, cough
Other complaint
• Headache, retro orbital pain
• Joint pain, back pain (backborne fever)
• Weakness, malaise
• Flushing: face, neck
• Photophobia, cough
Dengue Fever (2)Dengue Fever (2)
Skin rash
Primary rash
Rash: morbilliform (maculopapule):
chest and joint fold
Secondary rash
After day-4, especially day-6 or day-7
Maculopapule/petechiae /purpura/mixed
Confluence: usually hand and foot
Sometimes itching
Skin rash
Primary rash
Rash: morbilliform (maculopapule):
chest and joint fold
Secondary rash
After day-4, especially day-6 or day-7
Maculopapule/petechiae /purpura/mixed
Confluence: usually hand and foot
Sometimes itching
Dengue Fever (3)Dengue Fever (3)
• Hemorrhage ?
• Although not usual hemorrhage - petechiae (skin) - epistaxis - gum bleeding, vomiting/with blood - menorrhage
• Hemorrhage ?
• Although not usual hemorrhage - petechiae (skin) - epistaxis - gum bleeding, vomiting/with blood - menorrhage
Dengue Fever (4)Dengue Fever (4)
I VIV VII VIIIIIIII IV
36 oC
39 oC
40 oC
38 oC
37 oC
Pattern of Fever in Dengue Infection Pattern of Fever in Dengue Infection
Primary rash Primary rash Secondary rash Secondary rash
Dengue Virus Infection
FlushingPetechia
Secondary rash (convalescent rash)Secondary rash (convalescent rash)
MeningococcemiaMeningococcemia
Etiology: Neisseria meningitidis Etiology: Neisseria meningitidis (meningococcus)(meningococcus)
Clinical manifestationsClinical manifestations
– Acute fever, suddenly highAcute fever, suddenly high
– Hemorrhagic manifestations: petechiHemorrhagic manifestations: petechiaa, , purpura (fulminant)purpura (fulminant)
– Progressive severe Progressive severe meningitis, sepsis, meningitis, sepsis, septic shockseptic shock
Meningococcemia
VaricellaVaricella//ChickenpoxChickenpox Clinical manifestationsClinical manifestations Prodromal:Prodromal: 1–2 days,1–2 days, mild fever mild fever Papular erythromatous Papular erythromatous vvesicle esicle ppustule ustule crusta crusta Distribution of rash from body to faceDistribution of rash from body to face neck and extremitiesneck and extremities Pruritus +++Pruritus +++ Mucous membraneMucous membrane Spesific: several kinds of rash inSpesific: several kinds of rash in the same timethe same time
Varicella/ChickenpoxVaricella/Chickenpox
ComplicationComplication PneumoniaPneumonia (rare in children(rare in children, , high mortality inhigh mortality in immunocompromised hostsimmunocompromised hosts CeCerebelrebelllarar ataxia ataxia (1/4 (1/4..000000: : age age <15 yr) <15 yr) (Develops 7 to 10 days into the disease, (Develops 7 to 10 days into the disease, excellent prognosis)excellent prognosis) Transvere myelitis, Transvere myelitis, Guillain-Barre Guillain-Barre syndrome syndrome Hemorrhagic: thrombocytopeniaHemorrhagic: thrombocytopenia
Varicella/ChickenpoxVaricella/Chickenpox
ComplicationComplication SuperinfectionSuperinfection
- loc- localal: S. aureus: S. aureus or GABHS: cellulitisor GABHS: cellulitis
- systemic: GABHS: sepsis, necrotizing fasciitis, - systemic: GABHS: sepsis, necrotizing fasciitis, streptococcal streptococcal ttoxic oxic sshock hock ssyndromeyndrome
Reye Syndrome Reye Syndrome
PersistPersisteent vomiting, decreased mental status, nt vomiting, decreased mental status, liverliver
dysfunctiondysfunction
Associated with salicylate-containing productsAssociated with salicylate-containing products
Avoid aspirin in varicella !!!Avoid aspirin in varicella !!!
Hand-foot-mouth DiseaseHand-foot-mouth Disease
Etiologi Etiologi
- - CCoxackie virus typeoxackie virus type 16 (A 16)16 (A 16) >>>>
- - EEnterovirus 71nterovirus 71 encephalitis encephalitis
- Others: - Others: A5, A7, A9, A10, B2, B5 A5, A7, A9, A10, B2, B5
Fever, pharyngitis, salivationFever, pharyngitis, salivation
Self-limiting, simpSelf-limiting, simpttomatic therapy omatic therapy
HFMDHFMD HFMD
KKawasaki diseaseawasaki disease
First described in 1967First described in 1967 Incidence: 67 cases /100Incidence: 67 cases /100,,000 in Japan000 in Japan
5.6 cases/1005.6 cases/100,,000 in USA000 in USA 85% in children < 5 years (peak 18–24 mo)85% in children < 5 years (peak 18–24 mo)
Rarely occurs in adolescent, adults or children < Rarely occurs in adolescent, adults or children < 6 mo 6 mo
M/F ratio 1.4:1M/F ratio 1.4:1 Occurs often in late winter and springOccurs often in late winter and spring Etiology: UEtiology: Unknownnknown Pathophysiology: « Superantigen theory » causing Pathophysiology: « Superantigen theory » causing
an intense vasculitisan intense vasculitis
KKawasakiawasaki Disease Disease
Diagnosis: Diagnosis: fever lasting more than 5 daysfever lasting more than 5 days, plus , plus 4 of the following 5 criteria (other illnesses 4 of the following 5 criteria (other illnesses with similar clinical signs must be excluded):with similar clinical signs must be excluded):
1.1. Polymorphous rashPolymorphous rash
2.2. Bilateral conjunctival injectionBilateral conjunctival injection
3.3. One or more of the following mucous One or more of the following mucous membrane changes:membrane changes:
- Diffuse injection of oral and pharyngeal - Diffuse injection of oral and pharyngeal mucosamucosa
- Erythema or fissuring of the lips- Erythema or fissuring of the lips
- Strawberry tongue- Strawberry tongue
KKawasakiawasaki Disease Disease
4.4. Acute, nonpurulent cervical Acute, nonpurulent cervical lymphadenopathy (one lymph node must lymphadenopathy (one lymph node must be >1.5 cm)be >1.5 cm)
5. One or more of the following extremity 5. One or more of the following extremity changes:changes:
- Erythema of palms and/or soles- Erythema of palms and/or soles
- Indurative edema of hands and/or feet- Indurative edema of hands and/or feet
- Membranous desquamation of the - Membranous desquamation of the fingertipsfingertips
Polymorphous rash
Kawasaki Disease
One or more of the following One or more of the following extremity changesextremity changes
Erythema of palms and/ or soles
Indurative edema of hands and/or feet
Membranous desquamation of the fingertips
Bilateral conjunctival
injection
Strawberry tongue
Erythema or fissuring of the
lips
Nonpurulent cervical
lymphadenopathy
ConclusionsConclusions
Children Who Present Fever Children Who Present Fever and Rashand Rash
Group 1Group 1 : children with symptoms of serious illness who : children with symptoms of serious illness who require require
immediate intervention immediate intervention
Group 2Group 2 : children with a clearly recognizable-and usually : children with a clearly recognizable-and usually benign-benign-
viral syndromeviral syndrome
Group 3Group 3 : children who present early in the course of the : children who present early in the course of the disease, disease,
when the clinical picture and physical findings are when the clinical picture and physical findings are
nonspecific, and those with undifferentiated rashes nonspecific, and those with undifferentiated rashes with with
feverfever
Key Questions
Acute or Chronic (Recurrent)?
When did it start?
Pattern of Spread?
Sick or Well?
Pruritic?
Medications?
Exposures?
Describe What You See Pattern/Distribution
Diffuse or Localized? Mucous Membranes?
Palms & Soles? Exposed vs. Unexposed Areas?
Individual Lesions Color Size
Blanches? Characteristics
Other Physical Findings
Common Primary Skin Common Primary Skin LesionsLesions
MaculeMacule : Circumscribed area of change in normal skin color, : Circumscribed area of change in normal skin color, with no skin elevation or depression; may be any with no skin elevation or depression; may be any
sizesize
Papule Papule : Solid, raised lesion up to 0.5 cm in greatest : Solid, raised lesion up to 0.5 cm in greatest diameterdiameter
NoduleNodule : Similar to papule but located deeper in the dermis : Similar to papule but located deeper in the dermis or or
subcutaneous tissue; differentiated from papule by subcutaneous tissue; differentiated from papule by palpability and depth, rather than sizepalpability and depth, rather than size
PlaquePlaque : Elevation of skin occupying a relatively large area in : Elevation of skin occupying a relatively large area in relation to height; often formed by confluence of relation to height; often formed by confluence of papulespapules
Common Primary Skin Common Primary Skin LesionsLesions
Vesicle Vesicle : Circumscribed, elevated, fluid-containing lesion : Circumscribed, elevated, fluid-containing lesion less less
than 0.5 cm in greatest diameter; may be than 0.5 cm in greatest diameter; may be intraepidermal or subepidermal in originintraepidermal or subepidermal in origin
BullaBulla : Same as vesicle, except lesion is more than 0.5 : Same as vesicle, except lesion is more than 0.5 cm cm
in diameterin diameter
PustulePustule : Circumscribed elevation of skin containing : Circumscribed elevation of skin containing purulent purulent
fluid of variable character (i.e., fluid may be fluid of variable character (i.e., fluid may be white, white,
yellow, greenish or hemorrhagic)yellow, greenish or hemorrhagic)