FEVER WITH RASH:

DIFFERENTIAL
DIAGNOSES
 • An exanthem or exanthema is a widespread rash breakout
• When a rash is accompanied by a fever, it is called an
exanthematous fever
• Common in children—numerous aetiologies depending on the
type of rash and type of fever!
EXANTHEMS • Consider the following:

AND • Epidemiology and endemicity

• Season and environment
EVALUATION • Vaccination status
• Distribution/type of rash and relationship with the fever
• ?Drug history
• It is important to obtain a thorough history and exam as many
exanthems have significant overlap in their presentations!
CLASSICAL EXANTHEMS: FIRST THROUGH SIXTH
DISEASE

Measles, Scarlet Fever Rubella, Erythema Roseola

Rubeola, • ‘second disease’ German Measles Infectiosum Infantum,
Morbili • Streptococcus • ‘third disease’ • ‘fifth disease’ Exanthema
• ‘first disease’ pyogenes • Rubella togavirus • Parvovirus B19 Subitum
• Measles • Close contact • Droplet and • Droplet, • ‘sixth disease’
paramyxovirus • Strep throat is a aerosolisation aerosolization, • ?HHV-6, ?HHV-7
• Droplet and major risk factor blood-borne • Saliva, ?vertical
aerosolisation (10%!) transmission
 Macular, • Classic exanthems, dengue, drug-induced, adenovirus
Maculopapular, Papular • EBV, brucellosis, SLE, idiopathic juvenile arthritis, early smallpox,
rickettsial infections, enteric fever, leptospirosis, kala-azar
Rash
• SJS/TEN, sunburn
Erythematous Rash ± • Toxic shock syndrome, severe scarlet fever, staphylococcal scalded
Desquamation skin syndrome, Lyme disease

COMMON • Chicken pox, hand-foot-mouth disease, acne

Vesicles or Pustules
INDIAN • Herpes simplex, late smallpox

EXANTHEMS Petechiae/Purpura
• Meningococcaemia, dengue, HSP
• Vasculitides, gonococcaemia, complicated measles

an overview • TB (erythema nodosum), drug induced, urticaria, allergies, eczema,

Nodules or Wheals contact dermatitis
• Molluscum contagiosum, fungal infections

The Great Imitator • Kawasaki disease

COMMON INDIAN EXANTHEMS
in depth
MEASLES
• Clinical features:
• Incubation: 10-14 days
• 3Cs: cough, coryza, conjunctivitis; 4D: 4-day high fever
• Itchy red maculopapular rash several days after fever begins (ears → neck
→ face → trunk/limbs); Koplik spots
• Resolves in 3 weeks
• Complications:
• Mild: altered bowel habits; severe: pneumonia, encephalitis, otitis,
keratitis; mortality: 2-3/1000
• Long-term: immune depression?
• Diagnosis:
• Clinical: fever for 3 days + 1 of 3 Cs ± Koplik spots
• Lab: anti-measles serum IgM/salivary or mucous IgA
• Treatment: Supportive (hydration + superinfections + fever), Vitamin A
• Prevention: Measles vaccine (MR ± mumps, varicella)
ERYTHEMA INFECTIOSUM

• Clinical features:
• Mainly affects children 5-15 years old
• Incubation: 4-28 days
• Prodromal phase: nonspecific ssx (headache, low fever, URTI)
• Illness proper: slapped-cheek erythema spreads caudally and rapidly clears
centrally to give lace-like pattern; rash lasts 1-3 weeks
• Complications: arthropathy/arthritis (esp. adolescents), ITP, aseptic meningitis,
aplastic crises (k/c/o sickle cell), myocarditis; pregnant schoolteachers/school
staff should worry about hydrops!
• Treatment: supportive (fever); by adulthood, most people are immune
ROSEOLA INFANTUM

• Clinical features:
• Mainly affects children 6-36 months old
• Prodromal period: URTI ssx + cervical nodes ± palpebral
oedema
• Illness proper: high fever lasting 3-4 days + high risk of
febrile seizures
• Abrupt offset of fever followed within 24 hours by
nonpruritic discrete maculopapular rash that begins in
trunk and moves centrifugally, disappearing in 24 days
• Complications: not common
• Diagnosis: clinical. Outbreaks unlikely as infectivity is low
• Treatment: supportive (fever); self-limiting
CHICKEN POX
• Clinical features:
• Incubation: 10-21 days; severity based on host immunity
• Red macules → papules → clear vesicles → cloudy vesicles → crusted
vesicles → scabs (infective until 2-3 days after scabs fall off); 10-1500 lesions
at any point!
• Complications:
• Common: superinfections of skin lesions
• CNS: meningoencephalitis, GBS
• Vascular: vasculitis, fulminant purpura, ITP
• Diagnosis: mainly clinical. Anti-VZV IgM and Tzanck smear for atypical cases.
• Treatment: supportive (itches, fever, hygiene); quarantine; complications:
acyclovir/valacyclovir, VZIG
• Prevention: VZV vaccine (?MMRV); VZIG for PEP
INFECTIOUS
MONONUCLEOSIS
• Complications: (rare) encephalitis, haemolysis →
hypersplenism → splenic rupture, airway obstruction,
myocarditis, hepatitis, interstitial pneumonitis, ?non-Hodgkin
lymphoma
• Diagnosis:
• Lab: leukocytosis + absolute lymphocytosis, heterophile
antibody test (aka Paul-Bunnell test), anti-EBVCA IgM
• Treatment: rest, supportive; steroids for complications
MUMPS
• Clinical features:
• Mainly affects children 5-15 years old
• Incubation: 2-4 weeks
• Fever, malaise, headache followed by uni-/bilateral swelling of parotid ± other
salivary glands
• Complications: epididymoorchitis (but infertility rare), aseptic meningitis,
encephalitis, GBS, transverse myelitis
• Diagnosis:
• Clinical: as above
• Lab: anti-mumps IgM, serum amylase
• Treatment:
• Prevention: MMR vaccine
HAND-FOOT-MOUTH
DISEASE
• Clinical features:
• Mainly affects children <5 years old
• Prodromal period: low fever, malaise, sore throat
• Illness proper: oral ulcers/blisters; papulovesicular rash on
volar surfaces → knees, elbows, saddle region
• Resolves rapidly within a week
• Complications: loss of… nails?!, aseptic meningitis,
encephalitis, ?flaccid paralysis—it is an enterovirus, after all
• Diagnosis: clinical. Differentiate from herpes/aphthous
ulcers/varicella!
• Treatment: supportive (fever + pain + soft diet); quarantine
DENGUE

• Diagnosis:
• Direct methods: virus isolation by
culture, viral DNA detection by PCR,
NS-1 antigen
• Indirect methods: IgM/IgG detection
• Supportive investigations: ↓platelet
count, ↑PCV, ↑liver enzymes, ↓WBC
count with relative lymphocytosis,
CXR for NCPO
SCARLET FEVER

• Clinical features:
• Incubation: 12 hrs–7 days; mostly children 5-15 yrs old
• Strep throat: moderate fever, inability to cough, follicular
tonsillitis + odynophagia, cervical nodes
• Rash after 12-48 hrs: spreading, erythematous, Pastia’s
lines w/ volar sparing; tongue: white strawberry → red
strawberry
• Desquamates 1 week later, lasts several weeks
• Complications: nonsuppurative (PSGN, RHD); suppurative
(cellulitis, otitis → mastoiditis, endocarditis, pneumonia,
sepsis, meningitis)
• Diagnosis: clinical + lab
• RDT: ↓sensitivity, ↑specificity; throat culture: gold standard
• Serology not useful
• Treatment: abx acc. to antibiotic sensitivity testing
• Prevention: hygiene, isolation, environmental changes
RICKETTSIAL INFECTIONS
• Prevalent infections: scrub typhus (O. tsutsugamushi), Indian spotted
fever (R. conorii), Q fever (C. burnetti)
• Clinical features:
• Incubation: 2-14 days
• Common symptoms: unrelenting headache, very high fever, anorexia,
myalgia, restlessness, GI distress; rash follows after few days
• Rash: discrete pale red blanching macules/maculopapules on limbs,
later spreading centripetally; affects palms and soles; may become
petechial → purpuric → ecchymotic → necrotic and gangrenous
• Q fever isn’t common in kids and doesn’t feature a rash!
• Management
• Empirical therapy should be started w/o lab diagnosis if clinically
suspicious; doxycycline is first line
• Weil-Felix test for rickettsials to be correlated clinically
• IgM antibody serology is available
• Prevention: avoidance of tick-infested areas, pet disinfection; abx PrEP
not recommended
KAWASAKI DISEASE
• Must be considered in all under-5s with fever without
focus >5days!
• Pathogenesis:
• Acute febrile mucocutaneous lymph node syndrome
• Necrotising vasculitis of medium-sized arteries
• Complications:
• Coronary artery aneurysms → rupture (or) thrombosis
→ MI; valvular heart disease; aortic aneurysm
• Cerebral ischaemia/infarction; CN palsy;
emotional/psychiatric issues; uveitis, optic
complications
• Intestinal ischaemia/gangrene; pseudo-obstruction
• Treatment:
• Single dose IVIG 2g/kg wt + aspirin 75-80 mg/kg
• Maintenance: aspirin 3-5 mg/kg/day
THANK
YOU