Fever and rash, various causes

• Trypanids are transient erythemas with indefinite outline that occur in West African trypanosomiasis (Trypanosoma brucei gambiense). The lesions can occur anywhere, but are noticed most frequently on the torso. They can be large (more than 10 cm in diameter) and are triggered by local warmth. Oedema will also occasionally be seen on the face. Fever, splenomegaly and enlarged lymph nodes in the neck suggest the diagnosis. Serology and detection of trypanosomes are essential.

• Various deep mycoses, such as histoplasmosis, cryptococcosis and Penicillium marneffei infection (in AIDS patients in Southeast Asia) can cause fever and skin lesions (pustular, ulcers, erythema nodosum lesions).

Other cosmopolitan diseases to be considered in the differential diagnosis:

• Still’s disease (juvenile rheumatoid arthritis) is characterised by fever, rash, iritis, splenomegaly and generalised lymphadenopathy. Arthralgia (joint pains) and muscle pain are frequent. Arthritis especially affects the larger joints, but might not occur at all. There is leucocytosis. Pleuritis and pericarditis can occur.

• Side effects of medication, such as in erythema multiforma and Stevens-Johnson syndrome, can occur with tetracyclines, sulphonamides, etc. Certain medicinal side effects occur more frequently in AIDS patients (e.g. with thiosemicarbazone, cotrimoxazole). Amoxycillin can trigger or aggravate mononucleosis rash.

• Kawasaki syndrome is a disease of unknown origin. In addition to fever and a morbilliform or scarlatiniform erythema, lesions of the mucosae (stomatitis and non-purulent conjunctivitis, leading to red eyes), a red strawberry tongue and red, dry lips also occurs. There is often cervical lymphadenopathy (mucocutaneous lymph node syndrome). Aseptic meningitis can occur, with mononuclear cells in the cerebrospinal fluid. Cough, diarrhoea, abdominal pain and vomiting occur. There is leucocytosis, thrombocytosis and proteinuria. Desquamation of the hands and feet occurs around days 10-18. There is a risk of complications with coronary aneurysms in 1-2%.

• Toxic shock syndrome can be caused by toxins of certain Staphylococcus aureus strains. The same bacteria can cause a very severe exfoliative dermatitis: the so-called Ritter syndrome or SSSS (Staphylococcal scalded skin syndrome).

• Vasculitis (e.g. leucocytoclastic [hypersensitivity] vasculitis, granulomatous vasculitis, giant cell vasculitis) can be caused by numerous diseases. Cutaneous rash can assume various forms. Henoch-Schönlein purpura is characterised by a maculopapular skin rash (palpable purpura), especially on the calves, buttocks and the lower abdomen. Recurring abdominal pain and joint pain are present. There is a risk of kidney involvement. The disease is related to IgA nephropathy (Berger’s disease).

• Sweet's syndrome is characterised by fever, painful red infiltrated plaques on the face and the extremities, especially the anterior and extensor parts, as well as on the upper part of the torso and the neck. The lesions can have a clear centre. There is neutrophilia, infiltration of the skin with polymorphonuclear cells, arthritis and ocular abnormalities (episcleritis and conjunctivitis).

Category: Medicine Notes