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Given the extremely broad differential diagnosis, the presentation of a patient with fever and rash often poses a thorny diagnostic challenge for even the most astute and experienced clinician. Rapid narrowing of the differential by prompt recognition of a rash’s key features can result in appropriate and sometimes life-saving therapy. This atlas presents high-quality images of a variety of rashes that are associated with fever, most of which have an infectious etiology.

FIGURE A1-1

A. Erythema leading to “slapped cheeks” appearance in erythema infectiosum (fifth disease) caused by parvovirus B19. B. Lacy reticular rash of erythema infectiosum. (Panel A reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-2

Koplik’s spots, which manifest as 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. The presence of the erythematous halo (arrow indicates one example) differentiates Koplik’s spots from Fordyce’s spots (ectopic sebaceous glands), which occur in the mouths of healthy individuals. (Courtesy of the Centers for Disease Control and Prevention.)

FIGURE A1-3

In measles, discrete erythematous lesions become confluent on the face and neck over 2–3 days as the rash spreads downward to the trunk and arms, where lesions remain discrete. (Reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005.)

FIGURE A1-4

In rubella, an erythematous exanthem spreads from the hairline downward and clears as it spreads. (Courtesy of Stephen E. Gellis, MD; with permission.)

FIGURE A1-5

Exanthem subitum (roseola), caused by human herpesvirus 6, occurs most commonly in young children. A diffuse maculopapular exanthem follows resolution of fever. (Courtesy of Stephen E. Gellis, MD; with permission.)

FIGURE A1-6

Erythematous macules and papules are apparent on the trunk and arm of this patient with acute HIV infection. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005.)

FIGURE A1-7

This exanthematous, drug-induced eruption consists of brightly erythematous macules and papules, some of which are confluent, distributed symmetrically on the trunk and extremities. Ampicillin caused this rash. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005.)

FIGURE A1-8

Erythema migrans is the early cutaneous manifestation of Lyme disease and is characterized by an erythematous patch, which may be confluent or annular and sometimes has a target appearance. (Reprinted from RP Usatine et al: Color Atlas of Family Medicine, 2nd ed. New York, McGraw-Hill, 2013. Courtesy of Thomas Corson, MD.)

FIGURE A1-9

Rose spots are evident as erythematous macules on the trunk of this patient with typhoid fever. (Courtesy of the Centers for Disease Control and Prevention.)

FIGURE A1-10

Systemic lupus erythematosus showing prominent malar erythema and minimal scaling. Involvement of other sun-exposed sites is also common. (Reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-11

Subacute lupus erythematosus on the upper chest, with brightly erythematous and slightly edematous coalescent papules and plaques. (Reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-12

Chronic discoid lupus erythematosus. Violaceous, hyperpigmented, atrophic plaques, often with evidence of follicular plugging (which may result in scarring), are characteristic of this cutaneous form of lupus. (Reprinted from K Wolff, RA Johnson, AP Saavedra: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 7th ed. New York, McGraw-Hill, 2013.)

FIGURE A1-13

The rash of Still’s disease typically exhibits evanescent, erythematous papules that appear at the height of fever on the trunk and proximal extremities. (Courtesy of Stephen E. Gellis, MD; with permission.)

FIGURE A1-14

Impetigo is a superficial group A streptococcal or Staphylococcus aureus infection consisting of honey-colored crusts and erythematous weeping erosions. (Reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-15

Erysipelas is a group A streptococcal infection of the superficial dermis and consists of well-demarcated, erythematous, edematous, warm plaques. (Reprinted from K Wolff, RA Johnson, AP Saavedra: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 7th ed. New York, McGraw-Hill, 2013.)

FIGURE A1-16

Top: Petechial lesions of Rocky Mountain spotted fever on the lower legs and soles of a young, otherwise healthy patient. Bottom: Close-up of lesions from the same patient. (Courtesy of Lindsey Baden, MD; with permission.)

FIGURE A1-17

Primary syphilis with firm, nontender chancres. (Courtesy of M. Rein and the Centers for Disease Control and Prevention.)

FIGURE A1-18

Secondary syphilis, demonstrating a papulosquamous truncal eruption.

FIGURE A1-19

Secondary syphilis commonly affects the palms and soles with scaling, firm, red-brown papules.

FIGURE A1-20

Condylomata lata are moist, somewhat verrucous intertriginous plaques seen in secondary syphilis.

FIGURE A1-21

Mucous patches on the tongue of a patient with secondary syphilis. (Courtesy of Ron Roddy; with permission.)

FIGURE A1-22

Tender vesicles and erosions in the mouth of a patient with hand-foot-and-mouth disease. (Courtesy of Stephen E. Gellis, MD; with permission.)

FIGURE A1-23

Septic emboli with hemorrhage and infarction due to acute Staphylococcus aureus endocarditis. (Courtesy of Lindsey Baden, MD; with permission.)

FIGURE A1-24

Erythema multiforme is characterized by erythematous plaques with a target or iris morphology, sometimes with a vesicle in the center. It usually results from a hypersensitivity reaction to infections (especially with herpes simplex virus or Mycoplasma pneumoniae) or drugs. (Reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-25

Scarlet fever exanthem. Finely punctate erythema has become confluent (scarlatiniform); accentuation of linear erythema in body folds (Pastia’s lines) is seen here. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-26

Erythema progressing to bullae with resulting sloughing of the entire thickness of the epidermis occurs in toxic epidermal necrolysis. This reaction was due to a sulfonamide. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005.)

FIGURE A1-27

Diffuse erythema and scaling are present in this patient with psoriasis and the exfoliative erythroderma syndrome. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-28

This infant with staphylococcal scalded skin syndrome demonstrates generalized desquamation. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-29

Fissuring of the lips and an erythematous exanthem are evident in this patient with Kawasaki disease. (Courtesy of Stephen E. Gellis, MD; with permission.)

FIGURE A1-30

Numerous varicella lesions at various stages of evolution: vesicles on an erythematous base and umbilicated vesicles, which then develop into crusting lesions. (Courtesy of the Centers for Disease Control and Prevention.)

FIGURE A1-31

Lesions of disseminated zoster at different stages of evolution, including pustules and crusted lesions similar to varicella. Note nongrouping of lesions, in contrast to herpes simplex or zoster (shingles). (Reprinted from K Wolff, RA Johnson, AP Saavedra: Color Atlas and Synopsis of Clinical Dermatology, 7th ed. New York, McGraw-Hill, 2013.)

FIGURE A1-32

Herpes zoster is seen in this patient taking prednisone. Grouped vesicles and crusted lesions are seen in the T2 dermatome on the back and arm (A) and on the right side of the chest (B). (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-33

A. Eschar at the site of the mite bite in a patient with rickettsialpox caused by Rickettsia akari. B. Papulovesicular lesions on the trunk of the same patient. C. Close-up of lesions from the same patient. (Reprinted from A Krusell et al: Emerg Infect Dis 8:727, 2002.)

FIGURE A1-34

Ecthyma gangrenosum in a neutropenic patient with Pseudomonas aeruginosa bacteremia.

FIGURE A1-35

Urticaria showing characteristic discrete and confluent, edematous, erythematous papules and plaques. (Reprinted from K Wolff, RA Johnson, AP Saavedra: Color Atlas and Synopsis of Clinical Dermatology, 7th ed. New York, McGraw-Hill, 2013.)

FIGURE A1-36

Disseminated cryptococcal infection. A liver transplant recipient developed six cutaneous lesions similar to the one shown. Biopsy and serum antigen testing demonstrated Cryptococcus. Important features of the lesion include a benign-appearing fleshy papule with central umbilication resembling molluscum contagiosum. (Courtesy of Lindsey Baden, MD; with permission.)

FIGURE A1-37

Disseminated candidiasis. Tender, erythematous, nodular lesions developed in a neutropenic patient with leukemia who was undergoing induction chemotherapy. (Courtesy of Lindsey Baden, MD; with permission.)

FIGURE A1-38

Disseminated Aspergillus infection. Multiple necrotic lesions developed in this neutropenic patient undergoing hematopoietic stem cell transplantation. The lesion in the photograph is on the inner thigh and is several centimeters in diameter. Biopsy demonstrated infarction caused by Aspergillus fumigatus. (Courtesy of Lindsey Baden, MD; with permission.)

FIGURE A1-39

Erythema nodosum is a panniculitis characterized by tender, deep-seated nodules and plaques usually located on the lower extremities. (Courtesy of Robert Swerlick, MD; with permission.)

FIGURE A1-40

Sweet syndrome is an erythematous indurated plaque with a pseudovesicular border. (Courtesy of Robert Swerlick, MD; with permission.)

FIGURE A1-41

Fulminant meningococcemia with extensive angular purpuric patches. (Courtesy of Stephen E. Gellis, MD; with permission.)

FIGURE A1-42

Erythematous papular lesions are seen on the leg of this patient with chronic meningococcemia (arrow indicates a lesion).

FIGURE A1-43

Disseminated gonococcemia in the skin is seen as hemorrhagic papules and pustules with purpuric centers, typically in a peripheral distribution near joints. (Courtesy of Daniel M. Musher, MD; with permission.)

FIGURE A1-44

Palpable purpuric papules on the lower leg are seen in this patient with cutaneous small-vessel hypersensitivity vasculitis. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-45

The thumb of a patient with a necrotic ulcer of tularemia. (Courtesy of the Centers for Disease Control and Prevention.)

FIGURE A1-46

This 50-year-old man developed high fever and massive inguinal lymphadenopathy after a small ulcer healed on his foot. Tularemia was diagnosed. (Courtesy of Lindsey Baden, MD; with permission.)

FIGURE A1-47

This painful trypanosomal chancre developed at the site of a tsetse fly bite on the dorsum of the foot. Trypanosoma brucei was diagnosed from an aspirate of the ulcer. (Courtesy of Edward T. Ryan, MD. N Engl J Med 346:2069, 2002; with permission.)

FIGURE A1-48

Drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome (DRESS/DIHS). This patient developed a progressive eruption exhibiting early desquamation after taking phenobarbital. There was also associated lymphadenopathy and hepatomegaly. (Courtesy of Peter Lio, MD; with permission.)

FIGURE A1-49

Many small, nonfollicular pustules are seen against a background of erythema with acute generalized exanthematous pustulosis (AGEP), typically resulting from a drug reaction. The rash began in body folds and progressed to cover the trunk and face. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-50

Smallpox is shown with many pustules on the face, becoming confluent (A), and on the trunk (B). Pustules are all in the same stage of development. C. Crusting, healing lesions are noted on the trunk, arms, and hands. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.)

FIGURE A1-51

Zika virus infection is shown with erythematous macules and papules on the arm and trunk (A) and on the foot (B). This patient also had conjunctival injection (C) and palatal petechiae (D). (Courtesy of Amit Garg, MD; with permission.)

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