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1. DR. MUKESH SIDANA JUNIOR RESIDENT GENERAL MEDICINE MODERATOR DR. SUCHITRA GARHWAL ASSISTANT PROFESSOR FEVER WITH RASH UNDER THE GUIDANCE OF DR. PRAKASH KESWANI SENIOR PROFESSOR AND HEAD OF UNIT

2. What Is Rash And Why Looking For Rash Is Important ? Rash is an area of skin that has changed in texture or colour. Skin may be warm, scaly, itchy or swollen. Many infectious and non infectious fever are associated with rash. These skin manifestation s may be the hallmark of contagious disease or may be an early sign of a life threatening infectious and serious non infectious disorder.

3. Pathogenesis of skin rash R ash can result from a local infectious process or due to any systemic illness. Any class of microbe that has been allowed to penetrate the stratum corneum layer of skin and multiply locally may produce rash. Microorganisms produce skin eruptions by:- Multiplication in skin Release of toxin that act on skin structures Evoking an inflammatory response involving phagocytes and lymphocytes Via effects on vasculature, including vaso -occlusion and necrosis and/or vasodilation with edema an hyperemia .

4. The differential diagnosis of fever with rash is broad. But detailed history and clinical examination can establish a probable etiology for a di lig ent clinician.

5. Important Epidemiological Clues In History Age of the patient Season of the year in which patient come to you Travel history Geographic location Exposure to insects (especially ticks and mosquitoes) and animals (both wild and domestic ) History of animal bites Medications taken within previous month Immune status Recent dietary exposures Recent exposure to ill individuals Sexual exposure Immunisation status

6. Important Points In History Regarding Rash Timing of onset in relation to fever Site of first appearance Distribution and progression of rash Change in morphology I.e earlier flat now fluid filled Symptom associated with the rash(eg. pain, pruritis , pigmentation)

7. PHYSICAL EXAMINATION To narrow down the diagnosis we have to determine which type of lesions make the eruption Macule Papule Maculopapular Plaque Vesicle Bullae Nodule Target lesion Pustule Petechia Excoriation Exfoliation

8. MACULE A flat circumscribed non palpable lesion that differes in colour from the surrounding skin. It can be of any colour or shape. It is less than 1cm in diameter, larger lesions are a patch.

9. PAPULE An elevated solid lesion that is less than 1 cm in diameter.

10. MACULOPAPULAR Rash consisting of both Macule and Papule

11. PLAQUE An elevated circumscribed lesion greater then 1 cm in diameter, its surface is usually flat .

12. NOULE A solid palpable lesion in the dermis or subcutis , which can be observed as an elevation or can be palpated. It is more than 0.5 cm in diameter .

13. VESICLES AND BULLAE A vesicle is a circumscribed elevation less than 1 cm in diameter that contains fluid (clear, serous or haemorrhagic) and often grouped. Bullae are more than 1 cm in diameter, and should be subdivided as multilocular (due to coalesced vesicles, typically in eczema) or unilocular .

14. PUSTULE A circumscribed lesion that contains purulent material. It m ay occur within a pilosebaceous follicle or a sweat duct or, less often, on glabrous skin. Most commonly due to infections, but some eruptions typically cause sterile pustules.

15. TARGET LESION These are less than 3 cm in diameter and have three or more zones, usually a central area of dusky erythema or purpura, a middle paler zone of oedema, and an outer ring of erythema with a well defined edge .

16. PETECHIA A punctate haemorrhagic spot, approximately 1–2 mm in diameter .

17. EXCORIATION Loss of skin substance, specifically produced by scratching.

18. EXFOLIATION The splitting off of the epidermal keratin in scales or sheets.

19. CLASSIFICATION OF RASH On the basis of lesion morphology and distribution Centrally Distributed Maculopapular Eruptions Peripheral Eruptions Confluent Desquamative Erythemas Vesicobullous or Pustular Eruptio n s Urticaria like eruptions Nodular Eruptions Purpuritic Eruptions Eruption with Ulcers and/or Esch a r

20. 1. Centrally Distributed Maculopapular Eruptions In centrally distributed rashes lesions are primarily truncal Measles ( Rubeola / First Disease) Rickettsial Diseases German Measles (Rubella / Third Disease) Leptospirosis Erythema Infectiosum (Fifth Disease) Lyme disease Exanthem Subitum ( Roseola / Sixth Disease) Zika virus infection Dengue Fever Rat bite fever Typhoid Fever Relapsing Fever Primary HIV Infection SLE Acute Meningococcemia Rheumatic Fever ( Erythema Marginatum ) Infectious Mononucleosis Still disease Exanthematous Drug Eruptions Southern Tick Associated Rash Illness (STARI / Master’s Disease)

21. Measles Also known as Rubeola and First Disease Causative agent- Measles Virus Genus- Morbillivirus Family- Paramyxoviridae Transmitted mainly by respiratory droplets and less commonly by aerosol Incubation Period- 10-14 days Clinical Features - Fever, malaise, cough, coryza, conjunctivitis, characteristic rash and Koplik spots

22. RASH- Begin as erythematous macules behind the ears progress to involve the face, trunk, arms and legs fades slowly in the same order of progression Resolution of rash followed by desquamation Rash may not develop in persons with imapired immunity KOPLIK SPOTS - white or bluish lesions with an erythematous halo on the buccal mucosa, usually occur in the first 2 days of measles symptoms and may briefly overlap the measles exanthem first appear opposite to 2nd lower molar, later involve entire buccal mucosa. Pathognomonic of Measles

23. Complications - Common- Otitis Media, Bronchopneumonia Rare complicatios - Post Measles Encephalitis, Measles inclusion body encephalitis, Subacute sclerosing panencephalitis Prevention - Active and Passive Immunization Passive immunization - administration of human immunoglobulin within 72 hrs of exposure can prevent measles Active Immunization - live attenuated vaccine i.e. Edmonston and Schwarz strain Treatment - no specific antiviral therapy hydration and antipyretic agents Vitamin A - for 2 consecutive days to all children with measles ; 2 lakh IU for greater then 12 months , 1 lakh IU for 6 -12 months and 50000 IU for less then 6 months 3rd dose is recommended 2-4 wks later for children with evidence of vitamin A deficiency

24. Rubella Also known as German Measles and Third Disease Causative agent - Rubella Virus Genus - Rubivirus Family - Matonaviridae Transmitted by respiratory droplets Incubation Period - 14 days (12-23 days) Clinical Manifestations - Acquired Rubella and Congenital Rubella Syndrome Acquired Rubella - Generalised maculopapular rash, lymphadenopathy occipital and postauricular, arthralgia and arthritis Congenital Rubella Syndrome - Triad of Gregg- Cataract, Congenital Heart Disease(PDA), SNHL ; other features - Blueberry Muffin Rash (dermal erythropoiesis) , Hepatosplenomegaly, Interstitial Pneumonitis

25. RASH Maculopapular spreads from hairline downwords clear as it spreads difficult to detect in person with darker skin Forchheimer Spots Discrete rose colour spots on soft palate may extend over fauces

26. Complications encephalitis, thrombocytopenia Prevention Vaccination with RA 27/3 virus strain Immunoglobulin does not prevent Rubella virus infection after exposure so not recommended except in pregnent women not willing for MTP. Treatment no specific therapy symptom based treatment

27. Erythema Infectiosum Also known as Fifth Disease and Slapped Cheek Disese Causative agent - Human Parvo B19 Genus - Erythropapovavirus Exclusively infects humans Transmitted by respiratory droplets, blood transfusion Receptor - Blood group P antigen so replicates primarily in erythroid pregenitors Clinical Manifestations i.e. erythema infectiosum, polyarthropathy syndrome, transient aplastic crisis , pure red cell aplasia, hydrops fetalis

28. Rash of Erythema Infectiosum Classical facial rash - Erythematous and macular, develop after several days of febrile prodrome Lacy Reticlar Rash - on extremities, lacy reticular pattern, develop 2-3 days later of facial rash Treatment - symptomatic

29. Exanthum Subitum Also known as Roseola Infantum and 6th disease Causative agent- HHV6 > HHV7 Infects young children (9-21 months) Transmitted by saliva and genital secretions Clinical Features- Fever, fussiness, diarrhoea and rash Rash - diffuse, maculopapular, follows resolution of fever

30. Dengue Also known as Break Bone Fever Causative agent - Dengue Virus 1-4 Family - Flaviviridae Transmitted by bite of mosquito Adese Aegypti Incubation Period - 4-7 days Clinical Manifestations - Three Phases Febile Phase Critical phase Recovery Phase

31. Clinical Features - fever(Saddle Back) , frontal headache , retro orbital pain , myalgia, back pain, rash, adenopathy, palatal vesicles, scleral injection, anorexia, vomiting, dysguesia, marked cutaneous hypersensitivity, epistaxis, bleeding from gums, hematuria etc. Rash - transient macular rash on day 1 of fever(skin appear flushed) After 3-5 days when fever subsides a maculopapular rash develops. Begins from trunk, then spreads to extremities and face sparing palm and soles

32. Typhoid Fever Causative agent - Salmonella typhi By contaminated food and water Incubation Period - 10-14 days Clinical Manifestation - Fever (most prominant symptom) , chills , headache, cough, sweating, myalgia, malaise, arthralgia, rash (Rose spots) , epistaxis GI manifestations - anorexia, abdominal pain, nausea, vomiting, diarhoea more commonly then constipation Neurological manifestations - meningitis, GBS, neuritis, neuropsychriatric symptoms as Muttering Delirium or Coma Vigil Examination Findings - Rash , hepatosplenomegaly, relative bradycardia at peak of high fever

33. Rash (Rose spots) transient blanchable erythematous macule and papules 2-4 mm size usually on trunk

34. HIV Causative agent - HIV 1 and 2 Genus - Lentivirus Family - Retroviridae Transmitted by multiple routes i.e. sexual(mc mode), IV drug abuse, blood transfusion, mother to child transmission Incubation Period - 3-6 wks Clinical Features of Acute HIV Infection General - fever, pharyngitis, lymphadenopathy, headache, arthralgias, anorexia, nausea , vomiting Neurological - meningitis, encephalitis, peripheral neuropathy Dermatological - erythematous maculopapular rash, mucocutaneous ulceration

35. Rash - diffuse macule and papule found on upper thorax, face, collar region sometimes urticarial and vesicular lesions

36. Scrub Typhus Causative agent - O. tsutsugamushi Transmitted by bite of Trombiculoid mite Incubation Period - 6-21 days Clinical Manifestation - fever, headache, myalgia, cough, GI symptoms,lymphadenopathy, rash and eschar Rash - diffuse macular rash , start from trunk Eschar- at the site of bite

37. Lyme Disease Causative agent - Borrelia burgdorferi Transmitted by bite Ixodes tick Incubation Period - 3-32 days Clinical Manifestation - Stage 1 (localised infection) - Annular Rash (Erythema Migrans) Stage 2 (disseminated infection) - fever, headache, chills,migratory musculoskeletal pain, profound malaise and fatigue Stage 3 (persistent infection) - oligoarticular arthritis of large joints especially knees

38. Erythema Migrans Papule expand to form annular lesion with central clearing bright red outer border, central clearing and target centre Average diameter 15 cm multiple EM lesions can be present in some cases

39. Erythema Marginatum This is rash of Rheumatic Fever Rheumatic fever is multisystem disease resulting from an autoimmune reaction to infection with group A Streptococcus Clinical Features - Pharyngitis preceding polyarthritis, carditis, subcutaneous nodules, chorea Rash - Rash begin as macule that clears from centre and form polycyclic lesions occur over trunk and proximal extremities, never occur over face evolve and resolve within hours

40. Autoimmune disease common in reproductive age group females 5.5-6.5 times more prevalent in women than men Clinical Features - Fever, Rash, Arthritis, oral ulcers, nephritis, anemia, thrombocytopenia, delerium, psychosis etc. SLE

41. RASH OF SLE Acute Cutaneous Lupus Erythematosus (ACLE) Subacute Cutaneous Lupus Erythematosus (SCLE) Chronic Cutaneous Lupus Erythematosus (CCLE)

42. Localised ACLE - Malar Rash Also called Butterfly Rash superficial macular rash, non scarring, non premalignant symmetrical, spare nasolabial folds photosensitive distributed on sun exposed areas i.e. face, neck, extensor surface of arms, dorsal hands strong association with systemic disease Generalised ACLE - Morbilliform eruption over sun exposed areas spare the knuckles ACLE

43. Types - Annular(more common) and Psoriasiform more common in whites superficial, symmetrical, non scarring highly photosensitive mc site is trunk . spare mid facial region associated with antiRo/La antibodies induce by ACE inhibitors , CCBs, terbinafine etc. SCLE

44. Types - Classic discoid LE (DLE): (a) localized; (b) generalized Hypertrophic DLE/verrucous DLE Lupus panniculitis/profundus Mucosal DLE LE tumidus Chilblain LE Lichenoid DLE (DLE-lichen planus overlap) CCLE

45. Discoid LE (DLE) mc subtype of CCLE Localised limited to head and neck disc shaped raised erythematous plaque with adherent scsales classical sites- cheeks, nose,upper lips, also occur on scalp and neck follicular plugging is characteristic can result in permanant alopecia and disfiguration premalignant , SCC may develop

46. Hypertrophic LE chronic, indurated lesions that are covered by hyperkeratotic, multilayered scales visually and histologically resemble squamous cell carcinoma Lupus panniculitis lobular panniculitis has predilection for the scalp, face, arms, buttocks, and thighs Lupus profundus When cutaneous discoid lesion overlies the panniculitis, the entity is referred to as lupus profundus

47. Chilblain lupus tender, erythematous, or violaceous papules or plaques occurring on acral areas, especially the fingers, toes, heels, nose, and ears lesion increase by cold air Lupus tumidus edematous, erythematous plaques with a smooth surface highly photosensitive occur on zygomatic region of the face

48. 2. Peripheral Eruptions These rashes are most prominent peripherally or begin in peripheral areas before spreading centripetally . Rocky mountain spotted fever Secondary syphilis Chikungunya fever Hand-foot-and-mouth disease Erythema multiforme Rat bite fever ( haverhill fever ) Bacterial endocarditis

49. Chikungunya Fever Causative agent - Chikungunya Virus Family - Togaviridae Genus - Alphavirus Transmitted by bite of mosquito Aedes Aegypti and Aedes albopictus Incubation Period- 2-10 days Clinical Manifestations- fever(Saddle Back) , headache, myalgia, severe arthalgia , migratory polyarthritis mainly involving small joints of ankle, feet, hands, back pain, rash, scleral injection, anorexia, vomiting, photophobia

50. Rash maculopapular occurs around day 2-3 of disease, often coincides with defervescence most intense on limbs and trunk can be bullous in children

51. Syphilis Causative agent - Treponema pallidum Transmitted mainly by sexual route. others are infection in utero, blood transfusion, organ transplantation Incubation Period - 2-6 wks Clinical Manifestations Primary Syphilis- Chancre develops Secondary Syphilis Latent Syphilis- positive serology, normal CSF and absence of clinical manifestations Tertiary Syphilis- Gumma develpos

52. Secondary Syphilis Classical Manifestations - Mucocutaneous lesions Generalised non tender lymphadenopathy Mucocutaneous lesions skin rash mucous patches condyloma lata Alopecia

53. Skin rash - they do not itch coppery red in colour symmetrically distributed initially pale red non pruritic , discrete macules on trunk and extremities later progress to papular lesion which frequently involve palms and soles Mucous patches - silver grey in colour, painless involve oral and genital mucosa

54. Condyloma lata - pink , moist, highly infectious lesions occurs in intertriginous areas eg. perianal region, scrotum , vulva Alopecia - Moth Eaten alopecia is seen Characteristic of syphilis

55. Hand Foot And Mouth Disease Causative agent - Coxsackie virus A16 and Enterovirus 71 Family - Picornaviridae Incubation Period - 4-6 days Clinical Manifestations- Fever, anorexia , malaise followed by development of sore throat and vesicles vesicles develop on buccal mucosa, dorsum of hands, sometimes palms and soles quickly ulcerates

56. Erythema Multiforme Occur as target lesions, central erythema surrounded by area of clearing and another rim of erythema . sometimes vesicle present in centre. upto 2 cm size symmetrical spread centripetally occur over knees, elbows, palms, soles when involve mucous membrane then called EM major It usually results from a hypersensitivity reaction to infections (especially with herpes simplex virus or Mycoplasma pneumoniae ) or drugs eg. sulfa drugs, penicillin , phenytoin

57. Bacterial Endocarditis Causative agents - Streptococcus and Staphylococcus Modified Duke Criteria Clinical Manifestations - fever, chills with sweating, headache, myalgia, arthalgia, weight loss, murmur, splenomegaly, clubbing, neurological manifestations Laboratory manifestations - anemia, lekocytosis, microscopic hematuria, raised ESR, raised CRP, decreased serum complements

58. Janeway lesion - classical non suppurative peripheral manifestation of acute IE , these are painless erythematous macules present on palms and soles, non tender Splinter hemorrhage - petechiae on skin and mucosa both are due to septic embolization Osler nodes - tender , pink nodes on finger or toe pads 1mm to 10mm sign of subacute IE due to vasculitis

59. 3. Confluent Desquamative Erythemas Scarlet Fever Kawasaki Disease Staphylococcal scalded skin syndrome SJS and TEN DRESS These eruptions consist of diffuse erythema frequently followed by dequamation

60. Scarlet Fever Also known as Second Disease Causative agent - Group A Streptococcus Toxins - Pyrogenic exotoxins A,B,C Most common in 2-10 yr old children Clinical Features - fever , headache , pharyngitis , rash Rash - Sandpaper Rash - diffuse blanchable erythema, begin on face then spread to trunk and extremities Pastia Lines - linear erythema in skin folds Red Strawberry Tongue

61. Kawasaki Disease Idiopathic Acute , febrile , multisystemic disease of children common in Children <8 years old Clinical Features - Fever, u/l cervical lymphadenopathy, pharyngitis, non purulent conjunctivitis, desquamation of skin of fingertips, edema of hands and feet, Strawberry tongue , Rash, coronary artery aneurysm Rash smilar to Scarlet fever

62. Staphylococcal scalded skin syndrome Causative agent - Staph aureus Toxin - Exfoliative toxin occurs in children <10 years old (called Ritter’s disease in neonates) Clinical Features - fever, lethargy, poor feeding, irritibility formation of tender , thin walled fluid filled bullae which rupture by gentle pressure Nikolsky sign positive

63. SJS And TEN SJS and TEN are characterized by blisters and mucosal/epidermal detachment resulting from full-thickness epidermal necrosis in the absence of substantial dermal inflammation Steven Johnson Syndrome(SJS )- <10% involvement of epidermis SJS/TEN overlap - 10-30% involvement Toxic Epidermal Necrolysis - >30% involvement Nikolsky sign positive Causes Drugs- allopurinol, anticonvulsants (lamtrigine, phenytoin), oxicam NSAIDs, Beta lactam antibiotics , nevirapine

64. DISH/DRESS Drug induced hypersensitivity syndrome/ Drug reaction with eosinophilia and systemic symptoms This is systemic drug reaction Clinical Features - prodrome of fever and flu-like symptoms Cutaneous involvement Lymphadenopathy hepatitis, nephritis, pneumonitis, myositis, and gastroenteritis in descending order leukocytosis ,often with eosinophilia but not always present Causative agents - Allopurinol, abacavir, hydoxylamine, phenytoin , lamotrigine etc.

65. Rash - Cutaneous involvement occur after 2-8 wk of initiation of drug in form of diffuse morbilliform eruption , facial swelling , edema in hand and feet

66. 4. Vesicobullous or Pustular Eruptios Varicella(Chickenpox) Variola(Smallpox) Pseudomonas hot tub folliculitis HSV E cthyma Gangrenosum Rickettsial Pox Fluid filled eruptions

67. Varicella (Chickenpox) Causative agent - Varicella Zoster Virus (HHV3) Family - Herpesviridae Humans are only reserviors Transmitted by respiratory droplets Incubation Period - 10-21 days Common and mild in children, severe in adults and immunocompromised Clinical Manifestations- low grade fever, malaise, rash

68. Rash - Hallmark of infection Sequence- Macule - Papule- Vesicle- Pustule- Crusting Macules (2–3 mm) evolving into papules, then vesicles (sometimes umbilicated), on an erythematous base (“dewdrops on a rose petal”) , pustules then crusting happens. Lesion occur in crops Appear first on trunk and face then rapidly spreads lesions of various stages found together lesions can be found on mucosa of pharynx and vagina lesions are intensely pruritic

69. Smallpox Causative agent - Variola major virus Family - Poxvirus Humans were only reservior Transmitted by respiratory droplets Incubation period - 10-14 days Eradicated globally in 1980 Clinical Manifestations- prodrome of fever, headace, backache, myalgia, rash

70. Rash - skin macules evolving to papules, then vesicles, then pustules over 1 week, with subsequent lesion crusting and scabbing by day 14 lesion initially appear on face and spread centrifugally from trunk to extremities, lesion prominant on extrimities All lesions are in same stage of development

71. Herpes Simplex Virus Diseases Causative agent - HSV 1 and 2 Family - Herpesviridae Incubation Period - 1-26 days (median 6-8 days) HSV1 common in children and young adults and HSV 2 in sexually active adults Clinical Manifestations Oral facial infections Genital infections Herpetic whitlow Eye infections CNS and PNS infections

72. Rash - After inoculation erythema develops which rapidly followed by hallmark painful grouped vesicles these may evolve into pustules that ulcerate, especially on mucosal surfaces orofacial infections are usually caused by HSV 1 and genital by HSV 2

73. 5. Urticaria like eruptions Urticarial Vasculitis It is leukocytoclastic vasculitis of small dermal vessels Cause - Seum sickness, connective tissue disease (SLE, Sjogren), drugs Clinical Features - fever, arthralgias/arthritis, rash Rash - Erythematous, edematous plaques, burning rather pruritis duration up to 5 days lack of complete blanching with compression

74. 6. Nodular Eruptions Erythema Nodosum Sweet Syndrome Bacillary Angiomatosis These diseases are associated with nodular eruptions

75. Erythema Nodosum It is a dermatological condition characterised by tender, subcutaneous nodules . These nodules are large, violaceous and non ulcerative usually present over shin can be associated with arthralgias Causes Infections - Streptococcal, fungal, Mycobacterial Drugs - sulfa drugs, penicillin, oral contraceptive Sarcoidosis Idiopathic

76. Sweet Syndrome It is acute febrile neutrophilic dermatosis Sweet syndrome is characterised by red to brown edematous plaques which are painful Sites - head, neck and upper extrimities there is dense dermal infiltrate of neutrophils in lesions Associated with malignancy (mc - AML ) IBD SLE Drugs- ATRA, G-CSF

77. 7. Purpuritic Eruptions Purpura Fulminans Disseminated gonococcal infection Viral hemorrhagic fever TTP/HUS Cutaneous small vessel vasculitis Rat bite fever These diseases are associated with purpuric eruptions

78. Purpura Fulminans These are large ecchymoses with irregular shapes evolving into hemorrhagic bullae and then into black necrotic lesions Caused by DIC

79. Disseminated Gonococcal Infection Causative agent - Neisseria gonorrhoeae Exclusive human pathogen Transmitted by sexual route Incubation Period - 2-7 days Clinical Manifestations Urethritis Cervicitis Proctatitis Conjunctivitis Arthritis

80. Rash - Initially papules (1–5 mm) form which evolve over 1–2 days into hemorrhagic pustules with gray necrotic centers. Distribution- upper extremities near joints

81. HUS/TTP Causative agent of HUS- E. coli 0157:H7 (Toxin - Shiga toxin) Cause of TTP- Antibodies against ADAMTS13 TTP triad - Microangiopathic hemolytic anemia Renal failure Thrombocytopenia HUS pentad includes fever and neurological manifestations also

82. 8. Eruption with Ulcers and/or Escher Scrub typhus Anthrax Tuleremia African trypanosomiasis E cthyma Gangrenosum Rickettsial Pox

83. Anthrax Causative agent - Bacillius anthracis Transmitted by exposure to infected animals or animal products or from exposure to spores Incubation Period - 2-5 days Clinical Manifestations Cutaneous Anthrax Pulmonary Anthrax Gastrointestinal Anthrax Anthrax Meningitis

84. Rash - initially small pruritic papule develops at the site of inoculation 1-2 day later vesicles develops around the lesion vesicle rupture and form eschar with black base this ulcer is surrounded by area of induration with non pitting edema

85. Tularemia Causative agent - Francisella tularensis Transmitted by exposure to ticks, flies and infected animals Incubation Period - 3-5 days Clinical Manifestations Ulceroglandular form(MC) Glandular form Oculoglandular form Oropharyngeal form Pneumonic form Typhoidal form

86. Rash - in ulceroglandular form at the site of inoculation erythematous tender papule develops which later ulcerate with raised border Other many types of eruptions may also occur eg. maculopapular, vesicopapular, acneiform, urticarial etc.

87. Miscellaneous Name Disease 1st disease Measles 2nd disease Scarlet Fever 3rd disease Rubella 4th disease Duke disease 5th disease Erythema Infectiosum 6th disease Roseola Infantum

88. Miscellaneous Cellulitis Erysipela Folliculitis Impetigo

89. Ecthyma Gangrenosum Pseudomonas Hot Tub Folliculitis Zika Rash - Maculopapular Rash Conjunctival Injection Palatal Petechiae

90. Case History- Pt was 42 yr old gentleman presented with Chief complaints - Abnormal involuntary body movements 25 days ago Fever since 8 days Rash since 8 days Pt was chronic alcoholic No history of any insect bite, recent travel but there was history of initiation of anti epileptic medication (Phenytoin) because of seizure episode he had 25 days back. On the basis of history our diffrential diagnosis were viral exanthem, drug induced exanthem and Steven Johnson syndrome.

91. EXAMINATION FINDINGS : Inguinal lymphadenopathy , facial and pedal edema was present. Maculopapular rash was present on trunk and extremities sparing palms and soles. Systemic examination was within normal limits.

92. INVESTIGATIONS: Viral markers were negative. Dengue, Chikungunya, Scrub were negative. Hb 12.7, TLC 9.8k (N 70%, L13%, E5.2%) SGOT/PT 38/41, S.urea/creat 19/0.99, S. Na+/K+ 135/4.2, S.TP/Alb 6.7/3.7. S.Total IgE 161.

93. Patient was diagnosed with DRESS. MANAGEMENT: Phenytoin was stopped and was switched to Tab. Levetiracetam 500mg BD. Inj. Methylprednisolone 1gm for 3 days followed Tab. Prednisolone 100mg/day. (1.5 - 2 mg/kg/day initial dose and then taper over 8 weeks )

94. Take Home Message Fever associated with rash is common presentation Skin manifestations may provide an early clue to underlying infectious or non infectious disease History regarding drug intake, recent travel, animal or insect bite is important Identification of pattern and distribution of rash can narrow down differential diagnosis so always look for that.

95. References Harrison’s textbook of internal medicine Rook’s textbook of dermatology Mandell, Douglas and Bennett principles and practice of infectious diseases Up to date Images : www.accessmedicine.in/harrison