II. Causes: Classic Exanthems (historical order of first identified)
- First: Rubeola (Measles)
- Second: Scarlet Fever (Streptococcus Pyogenes)
- Third: Rubella (German Measles)
- Fourth: Dukes' Disease (Coxsackievirus or Echovirus)
- Fifth: Fifth Disease (Erythema Infectiosum, Parvovirus)
- Sixth: Exanthem Subitum (Roseola Infantum, HH6, HH7)
III. Causes: Distribution of Febrile Eruption
- Central Eruptions (starts with head and neck, trunk)
- Viral Exanthem
- Drug Eruption
- Typhoid Fever
- Peripheral Eruptions (Centripetal Rash - starts on distal extremities)
IV. Causes: Petechial Eruptions in the Febrile Patient
- See Purpura (or Petechiae)
- Common and Urgent Causes
- Toxic Appearing Patient
- Rocky Mountain Spotted Fever
- Meningococcemia
- Rash may first appear blanching, maculopapular before becoming petechial
- Well-Appearing Patient
- Toxic Appearing Patient
- Viral Causes
- Coxsackievirus A9
- Echovirus 9
- Epstein-Barr Virus
- Cytomegalovirus
- Atypical Measles
- Viral Hemorrhagic Fever
- Arbovirus Infection
- Arenavirus Infection
- Other Causes
V. Causes: Diffuse Erythema and Desquamation in the Febrile Patient
- See Desquamation
- Most Common
- Kawasaki Disease
- Scarlet Fever
- Fever, Pharyngitis and diffuse, fine red papular rash (sandpaper) on trunk, caused by Group A Streptococcus
- Distinguish from Kawasaki Disease
- Toxic Shock Syndrome
- Diffuse Erythroderma with fever, Hypotension and multi-system organ dysfunction due to Strep or Staph
- Scalded Skin Syndrome
- Burn-like rash in toxic appearing infants and toddlers, starting on the face and genitalia
- Less Common
- Ehrlichiosis
- Streptococcus viridans bacteremia
- Enteroviral infection
- Toxic Epidermal Necrolysis
- Graft-versus-host reaction
- Erythroderma
- Generalized Pustular Psoriasis (von Zumbusch)
VI. Causes: Vesiculobullous Eruptions in the Febrile Patient
- See Vesiculobullous Rash
- Common
- Herpes Zoster (Shingles)
- Varicella Zoster Virus (Chicken Pox)
- In vaccinated children, breakthrough varicella causes central eruption, <50 lesions (dew-drop on rose petal)
- Hand Foot and Mouth Disease
- High fever and variably painful, maculopapular or vesicular lesions on hands, feet as well as Oral Mucosa
- Bullous Impetigo
- Staphylococcal Skin Infection typically on the extremities or face; some lesions may have honey-colored crust
- Less common
- Staphylococcal Bacteremia
- Gonococcemia
-
Immunocompromised Patient Causes
- Disseminated Herpes Simplex Virus
- Vibrio vulnificus (seafood exposure)
- Rickettsia akari
VII. Causes: Nodular Eruptions in the Febrile Patient
- See Nodular Lymphangitis
- See Subcutaneous Nodule
- Erythema Nodosum
- Disseminated fungal infection (Immunocompromised)
- Other rare causes
- Nocardia
- Pseudomonas
- Mycobacterium species
VIII. Causes: Important Blanching, Maculopapular Rashes in Febrile Children
-
Measles
- Rash preceded by cough, Coryza and Conjunctivitis and high fever (>39 C)
- Rash starts on day 2-4 of symptoms, scalp and face first, then spreads to body (see Central Eruptions above)
-
Parvovirus
- Slapped cheek on face, followed by lacy reticular rash on extremities (but spares palms and soles)
- Many viral causes of edematous, pupuric socks and gloves syndrome
-
Roseola
- Three days of high fever, Conjunctivitis, Rhinorrhea, irritability, followed by development of central erupting rash
- Diffuse, blanching maculopapular rash (first on trunk, then extremities)
-
Acute Rheumatic Fever
- Erythema Marginatum (pink rash, pale center, serpiginous margin)
- Associated with Jones Criteria (Migratory Arthritis, carditis, Nodules, Sydenham's Chorea)
-
Kawasaki Disease
- Variable non-vesicular rash associated with Conjunctivitis, adenopathy, strawberry Tongue and distal extremity edema
IX. References
- Behar and Claudius in Herbert (2020) EM:Rap 20(6): 6-8
- Cunha (1998) Crit Care Clin 14:35-53 [PubMed]
- McKinnon (2000) Am Fam Physician 62(4):804-16 [PubMed]
- Schlossberg (1996) Infect Dis Clin North Am 10:101-10 [PubMed]