II. Causes: Classic Exanthems (historical order of first identified)

  1. First: Rubeola (Measles)
  2. Second: Scarlet Fever (Streptococcus Pyogenes)
  3. Third: Rubella (German Measles)
  4. Fourth: Dukes' Disease (Coxsackievirus or Echovirus)
  5. Fifth: Fifth Disease (Erythema Infectiosum, Parvovirus)
  6. Sixth: Exanthem Subitum (Roseola Infantum, HH6, HH7)

III. Causes: Distribution of Febrile Eruption

  1. Central Eruptions (starts with head and neck, trunk)
    1. Viral Exanthem
      1. Rubeola (Measles)
      2. Rubella
      3. Parvovirus B19 (Erythema Infectiosum)
      4. Roseola Infantum (HH6)
    2. Drug Eruption
    3. Typhoid Fever
  2. Peripheral Eruptions (Centripetal Rash - starts on distal extremities)
    1. Erythema Multiforme
    2. Secondary Syphilis
    3. Meningococcemia
    4. Rocky Mountain Spotted Fever
    5. Dengue Fever
    6. Coxsachievirus

IV. Causes: Petechial Eruptions in the Febrile Patient

  1. See Purpura (or Petechiae)
  2. Common and Urgent Causes
    1. Toxic Appearing Patient
      1. Rocky Mountain Spotted Fever
      2. Meningococcemia
        1. Rash may first appear blanching, maculopapular before becoming petechial
    2. Well-Appearing Patient
      1. Henoch-Schonlein Purpura
        1. Afebrile, well appearing child with preceding viral syndrome in prior 1-3 weeks
        2. Symmetric lower extremity Petechiae and Purpura
  3. Viral Causes
    1. Coxsackievirus A9
    2. Echovirus 9
    3. Epstein-Barr Virus
    4. Cytomegalovirus
    5. Atypical Measles
    6. Viral Hemorrhagic Fever
      1. Arbovirus Infection
      2. Arenavirus Infection
  4. Other Causes
    1. Disseminated Gonococcus
    2. Staphylococcal Sepsis
    3. Thrombotic Thrombocytopenic Purpura

V. Causes: Diffuse Erythema and Desquamation in the Febrile Patient

  1. See Desquamation
  2. Most Common
    1. Kawasaki Disease
    2. Scarlet Fever
      1. Fever, Pharyngitis and diffuse, fine red papular rash (sandpaper) on trunk, caused by Group A Streptococcus
      2. Distinguish from Kawasaki Disease
    3. Toxic Shock Syndrome
      1. Diffuse Erythroderma with fever, Hypotension and multi-system organ dysfunction due to Strep or Staph
    4. Scalded Skin Syndrome
      1. Burn-like rash in toxic appearing infants and toddlers, starting on the face and genitalia
  3. Less Common
    1. Ehrlichiosis
    2. Streptococcus viridans bacteremia
    3. Enteroviral infection
    4. Toxic Epidermal Necrolysis
    5. Graft-versus-host reaction
    6. Erythroderma
    7. Generalized Pustular Psoriasis (von Zumbusch)

VI. Causes: Vesiculobullous Eruptions in the Febrile Patient

  1. See Vesiculobullous Rash
  2. Common
    1. Herpes Zoster (Shingles)
    2. Varicella Zoster Virus (Chicken Pox)
      1. In vaccinated children, breakthrough varicella causes central eruption, <50 lesions (dew-drop on rose petal)
    3. Hand Foot and Mouth Disease
      1. High fever and variably painful, maculopapular or vesicular lesions on hands, feet as well as Oral Mucosa
    4. Bullous Impetigo
      1. Staphylococcal Skin Infection typically on the extremities or face; some lesions may have honey-colored crust
  3. Less common
    1. Staphylococcal Bacteremia
    2. Gonococcemia
  4. Immunocompromised Patient Causes
    1. Disseminated Herpes Simplex Virus
    2. Vibrio vulnificus (seafood exposure)
    3. Rickettsia akari

VII. Causes: Nodular Eruptions in the Febrile Patient

VIII. Causes: Important Blanching, Maculopapular Rashes in Febrile Children

  1. Measles
    1. Rash preceded by cough, Coryza and Conjunctivitis and high fever (>39 C)
    2. Rash starts on day 2-4 of symptoms, scalp and face first, then spreads to body (see Central Eruptions above)
  2. Parvovirus
    1. Slapped cheek on face, followed by lacy reticular rash on extremities (but spares palms and soles)
    2. Many viral causes of edematous, pupuric socks and gloves syndrome
  3. Roseola
    1. Three days of high fever, Conjunctivitis, Rhinorrhea, irritability, followed by development of central erupting rash
    2. Diffuse, blanching maculopapular rash (first on trunk, then extremities)
  4. Acute Rheumatic Fever
    1. Erythema Marginatum (pink rash, pale center, serpiginous margin)
    2. Associated with Jones Criteria (Migratory Arthritis, carditis, Nodules, Sydenham's Chorea)
  5. Kawasaki Disease
    1. Variable non-vesicular rash associated with Conjunctivitis, adenopathy, strawberry Tongue and distal extremity edema

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