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Drug Allergic Reaction
- erythematous maculopapular rash generally confluent, hives less
frequent; onset from 1 -2 days to 1 week after starting medication;
pruritic, afebrile; spreads distally;
Rx - D/C offending meds, Antihistamines (Benadryl),
? Prednisone; resolves slowly over 1- 2 weeks;
Complications interstititial nephritis, TEN (? burn unit admission)
Urticaria - General
hives, wheals, via acute dermal edema and erythema (lgE mediated,
histamine release), pruritic, erythematous borders with pale centers,
usually lasts < 24 hrs;
Etiology medications, insect bites or stings, food (seafood, nuts...),
soaps, chemicals, emotional stress, infections, sunlight, heat,
cold; Rx - Benadryl, SQ Epinephrine, ?Prednisone,
D/C offending agent or medication; DDx - Erythema
Multiforme (fixed, lasts > 24 hrs, Epinephrine no help; etiology-
HSV, Mycoplasma, Penicillin, Cephalosporins, Sulfa...)
Chicken-Pox (Varicella)
Background - common and usually benign disease,
>90% of children infected by age 10, highly infectious via vesicles
or respiratory tract (coughing, sneezing); Incubation:
1 -3 weeks  Prodrome
(fever, headache, flu like symptoms, malaise)
Rash
Physical Exam (PE) - red macules
1 -2 mm vesicles with a light red erythematous base which may follow
flu like symptoms, after 1 -2 days vesicles become pustular and
them form crusts/scabs; lesions start on trunk and progress to arms,
legs, scalp, and oral mucosa (lips and inside mouth);
Labs - low WBC, ? Skin Biopsy, Tzanck smears, viral
culture
Rx Tylenol for fever (not aspirin
- may cause Reye's Syndrome), Calamine or Caladryl lotion, Benadryl
for itching, Acyclovir for severe disease or complications, oatmeal
bath
Note - Don't scratch blisters which may become
infected, ? prophylactic vaccination
Measles (Red Measles, Rubeola)
Background - highly contagious, infects skin and
respiratory tract, mortality -1:3000 secondary to complications;
Incubation: 1 -2 weeks
Prodrome for 3 - 4 days (cough,
coryza, conjunctivitis, fever, weakness, congestion, photophobia,
runny nose) Morbilliform
Rash. Adults and babies may have more severe symptoms
and complications.
PE - enlarging red - pink fine spots starting over
forehead, behind ears, and upper neck; spreading towards face, trunk,
and then arms and legs (2nd day of rash); facial rash merges; tiny
grey white papules on red base involve lips, gums, and intraoral-buccal
mucosa (Koplik spots); rash associated with fever;
rash disappears with fine skin peeling
Complications - Conjunctivitis (red watery eyes),
ear infections, hearing loss, diarrhea, pneumonia, encephalitis,
seizures
Rx - Supportive care, Tylenol (not aspirin), rest;
Labs serum
titers (lgG, IgM)
Morbilliform Rash.
Adults and babies may have more severe symptoms and complications.
PE enlarging red - pink fine spots starting over
forehead, behind ears, and upper neck; spreading towards face, trunk,
and then arms and legs (2nd day of rash); facial rash merges; tiny
grey white papules on red base involve lips, gums, and intraoral-buccal
mucosa (Koplik spots); rash associated with fever;
rash disappears with fine skin peeling
Complications - Conjunctivitis (red watery eyes),
ear infections, hearing loss, diarrhea, pneumonia, encephalitis,
seizures
Rx - Supportive care, Tylenol (not aspirin), rest;
Labs - serum titers
(lgG, IgM)
Rubella (German Measles)
Background - less common; Incubation:
2- 3 weeks Mild
Prodrome 1 -4 days (URI symptoms), mild fever
Rash - lasts 1 -5 days; Caution
-can lead to abortions or fetal congenital abnormalIties (up to
50%) if pregnant when infected.
PE - maculopapular rash (small round raised and
flat spots <= 5 mm) starting at hairline and face and spreads
to trunk, arms and legs in 1 day, tender palpable lymph nodes (suboccipital,
posterior auricular), associated with arthritis (joint swelling);
rash does not become confluent
Rx - Supportive care, Tylenol (not aspirin), Benadryl,
rest
Atypical measles:
Background - status post receiving killed measles
vaccine in 1960's.
PE - vesicular red spoIling patchy rash over arms,
legs, hands, and feet; swelling of arms and legs; fevers, muscle
aches, headaches, abdominal discomfort, cough, pneumonia.
Rx - Supportive care, Tylenol (not aspirin), treat
complications
Roseola (Roseola Infantum,
Sixth Dis.) common, contagious, viral (Herpes Virus 6), < 2-3
yrs
PE/Symptoms often high fever (lasts 2 -5
days), cough
maculopapular rash (appears 2 days later - pink rosy red, 1 - 5
mm spots which may merge together but disappears in < 2 - 3 days),
rash initially appears over neck, chest, trunk, and abdomen and
spreads to arms, legs, and face; fever quickly decreases with rash
appearance; Rx - Tylenol, supportive care
Erythema Infectiosum
- (Fifth Disease, Parvovirus B19) - usually benign, generally in
young school aged children; no prodrome; red rash on cheeks "slapped
cheeks"; maculopapular rash spreading to trunk and
extremities; fever; duration 3-5 days; Complications
aplastic crises with hemoglobinopathies or HIV; Adults may get arthritis.
Infectious Mononucleosis
(Epstein Barr Virus - EBV, Mono) -common infection, Incubation.
2- 8 weeks, transmission via saliva contact, complete course of
IM 4-6 weeks
PE - fever, pharyngitis (sore throat - exudate
over tonsils), weakness, fatigue (weeks), enlarged neck lymph nodes,
enlarged spleen; rare - peripheral neuropathy, kidney inflammation,
anemia, liver infection; rare rash < 5%; with Ampicillin Rx rash
may occur up to 100%
Labs - TLC 5 - 10,000/mm3 (10-20% atypical lymphs),
+ Heterophile Ab;
Rx - Supportive care
Other Viral Exanthems
- Echoviruses, Coxsackievirus A and B, Adenovirus, Enteroviruses
Impetigo - (Bullous
- S. aureus, Impetigo Contagiosa)
Background - Contagious, Staph aureus or Streptococcus
(GABHS) skin infection
PE - vesicular, purulent, crusting, honey colored,
erythemetous or bullous lesions usually over face, arms,
or legs of variable size
Rx - Bactroban, Cephalosporins -Cephalexin, Dicloxacillin,
Erythromycin (50 mg/kg/day)
Scarlet Fever (group
A beta hemolytic streptococci - S. pyogenes)
Background Contagious streptococcal throat infection
(pharyngitis, tonsillitis) with fever, headache, nausea, ?vomit,
?abdominal pain -followed in 1-2 days by bright red rash (sandpaper
quality) spreading from face to neck, chest, back, skin folds, and
entire body over 3 - 4 days; followed by desquamation; strawberry
tongue; circumoral pallor;
Rx - Penicillin, Erythromycin;
Complications - rheumatic fever, glomerulonephritis,
pneumonia, meningitis
Toxic Shock Syndrome
- (via Staph. aureus exotoxin, occasionally Strep.) - high fever,
headache, vomiting, abdominal pain, diarrhea, myalgias, pharyngitis,
hypotension, confusion, diffuse macular erythematous rash (like
Scarlet fever) which later desquamates; effects 3 or more
organ systems (GI, renal, hepatic, CNS, heme, muscle);
Rx - D/C tampons, drain or remove nidus of infection,
hemodynamic support, ICU, anti-Staph (or ?Strep.) Antibiotics
Staphylococcal Scalded Skin Syndrome
- < 5 years old, exfoliative toxin
intraepidermal cleavage à bulla; local Staph infection nidus;
diffuse erythema; + Nikolsky's sign - pressing on skin
sliding of epidermis off skin; more likely to affect skin creases,
groin, axilla, neck; later desquamates; known as Ritter's disease
in the newborn;
Rx - Nafcillin, Oxacillin; admit
Meningococcemia
- (via N. meningitidis) -has red maculopapular rash or with petechiae
or purpura;
Symptoms - fever, chills, weakness, tachypnea,
meningitis (fevers, alteration of mental status,
stiff neck, shock, variable nonspecific symptoms);
Rx - IV Abx, ?prophylaxis
Ecthyma - Group A
Strep skin infection, through epidermis, usually on lower extremities,
? ulcer present, surrounding erythema;
Rx - Oral Antibiotics
Erysipelas - Streptococcal
cellulits with sharply distinct border;
Rx - Antibiotics
Lyme Disease (spirochete
Borrelia burgdorleri via tick Ixodes dammini)
Background - #1 tick-born infection, more common
< age 20.
Clinical stages - 1. Skin/systemic -tick
bite - expanding red spot (red macular rash) with demarcated rim
(Erythema chronicum migrans) - may be pustular, vesicular, crusting,
or central clearing; lesion must be > 5 cm; other red rings (or
curvilinear) elsewhere over skin; fevers, chills, muscle aches,
neck and joint stiffness, malaise, enlarged lymph nodes, headaches;
rash expands slowly days - weeks; 2. Neurologic/Cardiac (15-20%)
- heart block (AV), headaches, meningitis, radiculitis, cranial
nerve palsies (Bell's Palsy), optic neurtis, eye inflammations;
3. Arthritis -months - years after bite, knee #1 joint, potentially
affects all joints
Labs - Serologic tests (Elisa or Western Blot)
-may take 6 weeks after infection for positive results, and may
be seropositive without the disease in endemic areas
Rx - Erythromycin, Amoxicillin, Ceftin, Biaxin,
Ceftriaxone, Doxycycline ...
Rocky Mountain Spotted Fever
Background - infection (Rickettsia) spread by infected
ticks; Incubation. 2 - 5 days, associated with outdoor activities
especially in wooded areas
Clinical - fever, chills, fatigue, nausea, vomiting,
muscle pains, back pains, headaches, may be able to identify history
of tick bite; Red skin rash -starts about 4th day of fever
(secondary to vasculitis, erythematous macular rash to darker-papular-petechial
rash) starting at feet and hands (flexor sides) and spreads up arms
and legs to include chest and abdomen
Rx - Tetracycline, Chloramphenicol, supportive
care, usually requires hospitalization
Kawaski's Disease
- Mucocutaneous Lymph Node Syndrome, males usually 1.5 - 2 yrs old,
or < 10 yrs old; ?etiology; nonspecific vasculitis. Three
Phases: 1. Acute Phase (1-2 wks): fever up to 40 C, variable
rashes (scarlatiniform, morbilliform, measles like, urticaria, maculopapular),
conjunctivitis (nonpurulent), erythematous lips and mucous membranes,
strawberry tongue, palmar and plantar erythema and induration; unilateral
cervical lymphadenitis, tachycardia, gallop, CHF, myocarditis, pericardial
effusions, elevated ESR; 2. Subacute Phase (2-3
wks): less fever, desquamation, arthralgias, arthritis, nausea,
vomiting, diarrhea, abdominal pain, urethritis, hydrops of GB, thrombocytosis,
coronary artery dilation; 3. Convalescent Phase
(3-6 wks +): coronary artery dilation and aneurysms;
Rx - High dose ASA, IV Immunoglobulin;
Dx - fever > 5 days + 4/5 symptom groups (conjunctivitis,
cervical LNs, mucosal erythema, truncal exanthem, hands and feet
erythema - edema - later desquamation
Scabies - Transmitted
by a mite (small insect) directly from person to person; mites burrow
under the skin and deposit eggs and feces which causes moderate
to severe itching; Incubation: 3 weeks - 2 months
PE - scaling bumpy, red rash (papules) usually
over axilla, wrists, web spaces over fingers and toes, elbows, knees,
groin, genitalia, soles of feet, small burrows (with black dot at
end)
Rx - Lindane - Kwell (avoid with pregnancy and
< 6 months old), 6% Sulfur Ointment, Crotamiton Cream (Eurax),
5% Permethrin (Elimite) - per MD. Benadryl and corticosteroid cream
prn. Treat family members and sexual partners.
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