Demam Definisi: Kenaikan suhu tubuh diatas range normal suhu tubuh manusia pada umumnya, yaitu 36,537,5C;

yang dikarenakan oleh kenaikan set point pada hipotalamus. Suhu tubuh pada individu yang sehat apabila diukur di oral 33,2-38,2C; diukur di rektal 34,4-37,8C, diukur di rongga telinga 35,4-37,8C, dan bila diukur di aksila 35,5-37,0C. Tipe-tipe demam: 1. Demam septik - Suhu badan berangsur naik ke tingkat yang tinggi pada malam hari dan turun kembali ke tingkat diatas normal pada siang hari 2. Demam remiten - Suhu badan dapat turun setiap hari tapi tidak pernah mencapai suhu normal 3. Demam intermiten - Suhu badan turun ke tingkat yang normal selama beberapa jam dalam 1 hari 4. Demam kontinyu - Variasi suhu sepanjang hari tidak berbeda lebih dari 1 derajat 5. Demam siklik - Terjadi kenaikan suhu badan selama beberapa hari yang diikuti oleh periode bebas demam untuk beberapa hari yangkemudian diikuti oleh kenaikan suhu seperti semula Patofisiologi demam Once the hypothalamic set point is raised, neurons in the vasomotor center are activated and vasoconstriction commences. The individual first notices vasoconstriction in the hands and feet. Shunting of blood away from the periphery to the internal organs essentially decreases heat loss from the skin, and the person feels cold. For most fevers, body temperature increases by 12C. Shivering, which increases heat production from the muscles, may begin at this time; however, shivering is not required if heat conservation mechanisms raise blood temperature sufficiently. Nonshivering heat production from the liver also contributes to increasing core temperature. In humans, behavioral adjustments (e.g., putting on more clothing or bedding) help raise body temperature by decreasing heat loss. The processes of heat conservation (vasoconstriction) and heat production (shivering and increased nonshivering thermogenesis) continue until the temperature of the blood bathing the hypothalamic neurons matches the new thermostat setting. Once that point is reached, the hypothalamus maintains the temperature at the febrile level by the same mechanisms of heat balance that function in the afebrile state. When the hypothalamic set point is again reset downward (in response to either a reduction in the concentration of pyrogens or the use of antipyretics), the processes of heat loss through vasodilation and sweating are initiated. Loss of heat by sweating and vasodilation continues until the blood temperature at the hypothalamic level matches the lower setting.

Table 18-1 Diseases Associated with Fever and Rash

Disease Etiology Description Group Clinical Affected/Epidemio Syndrome logic Factors Chapt er

Centrally Distributed Maculopapular Eruptions Acute meningococcemi aa Rubeola (measles, first disease) Paramyxovirus 136

Discrete lesions Nonimmune that become individuals confluent as rash spreads from hairline downward, sparing palms and soles; lasts 3 days; Koplik's spots Spreads from hairline downward, clearing as it spreads; Forschheimer spots Nonimmune individuals

Cough, conjunctivitis, coryza, severe prostration

185

Rubella (German Togavirus measles, third disease)

Adenopathy, arthritis

186

Erythema Human parvovirus Bright-red infectiosum (fifth B19 "slapped-cheek" disease) appearance followed by lacy reticular rash that waxes and wanes over 3 weeks; rarely, papular-purpuric "gloves-andsocks" syndrome on hands and feet Exanthem subitum (roseola, sixth disease) Primary HIV infection Human herpesvirus 6

Most common in children aged 312 years; occurs in winter and spring

Mild fever; arthritis 177 in adults; rash following resolution of fever

Diffuse Usually affects maculopapular children <3 years eruption (sparing old face); resolves within 2 days Nonspecific Individuals recently diffuse macules infected with HIV and papules; may be urticarial; oral or genital ulcers in some cases Adolescents, young adults

Rash following 175 resolution of fever; similar to Boston exanthem (echovirus 16) Pharyngitis, adenopathy, arthralgias 182

HIV

Infectious mononucleosis

Epstein-Barr virus Diffuse maculopapular eruption (10

Hepatosplenomeg aly, pharyngitis, cervical

174

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors lymphadenopathy, atypical lymphocytosis, heterophile antibody

Chapt er

15% of cases; 90% if ampicillin is given); urticaria in some cases; periorbital edema (50%); palatal petechiae (25%) Other viral exanthems Echoviruses 2, 4, 9, 11, 16, 19, and 25; coxsackieviruses A9, B1, and B5; etc. Skin findings mimicking rubella or measles

Affect children more Nonspecific viral commonly than syndromes adults

184

Exanthematous drug-induced eruption

Drugs (antibiotics, Intensely anticonvulsants, pruritic, brightdiuretics, etc.) red macules and papules, symmetric on trunk and extremities; may become confluent Maculopapular eruption appearing in axillae, spreading to trunk and later to extremities; usually spares face, palms, soles; evolves from blanchable macules to confluent eruption with petechiae; rash evanescent in recrudescent typhus (BrillZinsser disease)

Occurs 23 d after Variable findings: exposure in fever and previously sensitized eosinophilia individuals; otherwise, after 23 weeks (but can occur anytime, even shortly after drug is discontinued) Exposure to body lice; occurrence of recrudescent typhus as relapse after 30 50 years

56

Epidemic typhus Rickettsia prowazekii

Headache, 167 myalgias; 1040% mortality if untreated; milder clinical presentation in recrudescent form

Endemic (murine) typhus

Rickettsia typhi

Maculopapular Exposure to rat or eruption, usually cat fleas sparing palms, soles Diffuse macular rash starting on trunk; eschar at site of mite bite Eschar common Endemic in South Pacific, Australia, Asia; transmitted by mites

Headache, myalgias

167

Scrub typhus

Orientia tsutsugamushi

Headache, 167 myalgias, regional adenopathy; mortality up to 30% if untreated 167

Rickettsial

Rickettsia conorii

Exposure to ticks; R. Headache,

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors conorii in myalgias, regional Mediterranean adenopathy region, India, Africa; R. australis in Australia; R. sibirica in Siberia, Mongolia

Chapt er

spotted fevers

(boutonneuse fever), Rickettsia australis (North Queensland tick typhus), Rickettsia sibirica (Siberian tick typhus), and others Ehrlichia chaffeensis

at bite site; maculopapular (rarely, vesicular and petechial) eruption on proximal extremities, spreading to trunk and face Maculopapular eruption (40% of cases), involves trunk and extremities; may be petechial Maculopapular eruption; conjunctivitis; scleral hemorrhage in some cases

Human monocytotropic ehrlichiosisb

Tick-borne; most Headache, common in U.S. myalgias, Southeast, southern leukopenia Midwest, and midAtlantic regions Exposure to water contaminated with animal urine

167

Leptospirosis

Leptospira interrogans

Myalgias; aseptic 164 meningitis; fulminant form: icterohemorrhagic fever (Weil's disease) Headache, 166 myalgias, chills, photophobia occurring acutely; CNS disease, myocardial disease, arthritis weeks to months later in some cases

Lyme disease

Borrelia burgdorferi

Papule Bite of tick vector expanding to erythematous annular lesion with central clearing (erythema chronicum migrans or ECM; average diameter, 15 cm), sometimes with concentric rings, sometimes with indurated or vesicular center; multiple secondary ECM lesions in some cases Transient, blanchable erythematous macules and papules, 24 mm, usually on trunk (rose spots) Rash in 50% of cases; initially diffuse flushing; midway through Ingestion of contaminated food or water (rare in U.S.)

Typhoid fever

Salmonella typhi

Variable abdominal 146 pain and diarrhea; headache, myalgias, hepatosplenomega ly

Dengue feverc

Dengue virus (4 serotypes; flaviviruses)

Occurs in tropics and subtropics; transmitted by mosquito

Headache, musculoskeletal pain ("breakbone fever");

189

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors leukopenia; occasionally biphasic ("saddleback") fever

Chapt er

illness, onset of maculopapular rash, which begins on trunk and spreads centrifugally to extremities and face; pruritus, hyperesthesia in some cases; after defervescence, petechiae on extremities in some cases Rat-bite fever (sodoku) Spirillum minus Eschar at bite site; then blotchy violaceous or red-brown rash involving trunk and extremities Central rash at end of febrile episode; petechiae in some cases

Rat bite; primarily Regional found in Asia; rare in adenopathy, U.S. recurrent fevers if untreated

...

Relapsing fever

Borrelia species

Exposure to ticks or body lice

Recurrent fever, 165 headache, myalgias, hepatosplenomega ly Pharyngitis preceding polyarthritis, carditis, subcutaneous nodules, chorea 315

Erythema marginatum (rheumatic fever)

Group A Streptococcus

Erythematous Patients with annular papules rheumatic fever and plaques occurring as polycyclic lesions in waves over trunk, proximal extremities; evolving and resolving within hours Macular and papular erythema, often in sun-exposed areas; discoid lupus lesions (local atrophy, scale, pigmentary changes); periungual telangiectasis; malar rash; vasculitis sometimes Most common in young to middleaged women; flares precipitated by sun exposure

Systemic lupus erythematosus

Autoimmune disease

Arthritis; cardiac, pulmonary, renal, hematologic, and vasculitic disease

313

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors

Chapt er

causing urticaria, palpable purpura; oral erosions in some cases Still's disease Autoimmune disease Transient 2- to 5- Children and young mm adults erythematous papules appearing at height of fever on trunk, proximal extremities; lesions evanescent High spiking fever, 331 polyarthritis, splenomegaly; erythrocyte sedimentation rate, >100 mm/h

Arcanobacterial pharyngitis

Arcanobacterium Diffuse, Children and young (Corynebacterium erythematous, adults ) haemolyticum maculopapular eruption involving trunk and proximal extremities; may desquamate

Exudative pharyngitis, lymphadenopathy

131

Peripheral Eruptions Chronic meningococcemi a, disseminated gonococcal infectiona, human parvovirus B19 infectiong Rocky Mountain spotted fever Rickettsia rickettsii 136, 137, 177

Rash beginning on wrists and ankles and spreading centripetally; appears on palms and soles later in disease; lesion evolution from blanchable macules to petechiae

Tick vector; widespread but more common in southeastern and southwest-central U.S.

Headache, myalgias, abdominal pain; mortality up to 40% if untreated

167

Secondary syphilis

Treponema pallidum

Coincident Sexually transmitted Fever, primary chancre constitutional in 10% of cases; symptoms copper-colored, scaly papular eruption, diffuse but prominent on

162

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors

Chapt er

palms and soles; rash never vesicular in adults; condyloma latum, mucous patches, and alopecia in some cases Atypical measles Paramyxovirus Maculopapular eruption beginning on distal extremities and spreading centripetally; may evolve into vesicles or petechiae; edema of extremities; Koplik's spots absent Tender vesicles, erosions in mouth; 0.25-cm papules on hands and feet with rim of erythema evolving into tender vesicles Target lesions (central erythema surrounded by area of clearing and another rim of erythema) up to 2 cm; symmetric on knees, elbows, palms, soles; may become diffuse; may involve mucosal surfaces; lifethreatening in maximal form (Stevens-Johnson syndrome) Individuals Headache, nodular 185 contracting measles pneumonia who received killed measles vaccine in 19631967 in U.S. without subsequent live vaccine

Hand-foot-andmouth disease

Coxsackievirus A16 most common cause

Summer and fall; primarily children <10 years old; multiple family members

Transient fever

184

Erythema multiforme

Drugs, infection, idiopathic causes

Drug intake (i.e., sulfa, phenytoin, penicillin); herpes simplex virus or Mycoplasma pneumoniae infection

Varies with d predisposing factor

Rat-bite fever Streptobacillus (Haverhill fever) moniliformis

Maculopapular Rat bite, ingestion of Myalgias; arthritis . . . eruption over contaminated food (50%); fever palms, soles, and recurrence in some

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors cases

Chapt er

extremities; tends to be more severe at joints; eruption sometimes becoming generalized; may be purpuric; may desquamate Bacterial endocarditis Streptococcus, Staphylococcus, etc. Subacute course: Abnormal heart Osler's nodes valve, intravenous (tender pink drug use nodules on finger or toe pads); petechiae on skin and mucosa; splinter hemorrhages. Acute course (Staphylococcus aureus): Janeway lesions (painless erythematous or hemorrhagic macules, usually on palms and soles) Diffuse blanchable erythema beginning on face and spreading to trunk and extremities; circumoral pallor; "sandpaper" texture to skin; accentuation of linear erythema in skin folds (Pastia's lines); enanthem of white evolving into red "strawberry" tongue; desquamation in second week Rash similar to scarlet fever Most common in children aged 210 years; usually follows group A streptococcal pharyngitis

New heart murmur 118

Confluent Desquamative Erythemas Scarlet fever Group A (second disease) Streptococcus (pyrogenic exotoxins A, B, C) Fever, pharyngitis, 130 headache

Kawasaki disease

Idiopathic causes

Children <8 years

Cervical adenopathy,

54, 319

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors pharyngitis, coronary artery vasculitis

Chapt er

(scarlatiniform) or erythema multiforme; fissuring of lips, strawberry tongue; conjunctivitis; edema of hands, feet; desquamation later in disease Streptococcal toxic shock syndrome Group A When present, Streptococcus rash often (associated with scarlatiniform pyrogenic exotoxin A and/or B or certain M types) S. aureus (toxic shock syndrome toxin 1, enterotoxin B or C)

May occur in setting Multiorgan failure, of severe group A hypotension; 30% streptococcal mortality rate infections, such as necrotizing fasciitis, bacteremia, pneumonia Fever >39C (102F), hypotension, multiorgan dysfunction

130

Staphylococcal toxic shock syndrome

Diffuse erythema Colonization with involving palms; toxin-producing S. pronounced aureus erythema of mucosal surfaces; conjunctivitis; desquamation 7 10 days into illness Diffuse tender erythema, often with bullae and desquamation; Nikolsky's sign

129

Staphylococcal scalded-skin syndrome

S. aureus, phage group II

Colonization with Irritability; nasal or 129 toxin-producing S. conjunctival aureus; occurs in secretions children <10 years old (termed "Ritter's disease" in neonates) or adults with renal dysfunction Usually occurs in adults over age 50; more common in men Fever, chills (i.e., 53, 56 difficulty with thermoregulation); lymphadenopathy

Exfoliative erythroderma syndrome

Underlying psoriasis, eczema, drug eruption, mycosis fungoides

Diffuse erythema (often scaling) interspersed with lesions of underlying condition Diffuse erythema or target-like lesions progressing to bullae, with sloughing and necrosis of entire epidermis; Nikolsky's sign. TEN: maximal

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN)

Drugs, other causes (infection, neoplasm, graftvs.-host disease)

Uncommon in children; more common in patients with HIV infection or graft-vs.-host disease

Dehydration, 56 sepsis sometimes resulting from lack of normal skin integrity; 25% mortality

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors

Chapt er

form of SJS. SJS: maximal form of erythema multiforme Vesiculobullous Eruptions Hand-foot-andmouth syndromee; staphylococcal scalded-skin syndrome; toxic epidermal necrolysisf Varicella (chickenpox) d

Varicella-zoster virus

Macules (23 mm) evolving into papules, then vesicles (sometimes umbilicated), on an erythematous base ("dewdrops on a rose petal"); pustules then forming and crusting; lesions appearing in crops; may involve scalp, mouth; intensely pruritic

Usually affects children; 10% of adults susceptible; most common in late winter and spring

Malaise; generally 173 mild disease in healthy children; more severe disease with complications in adults and immunocompromis ed children

Pseudomonas "hot-tub" folliculitis

Pseudomonas aeruginosa

Pruritic, Bathers in hot tubs erythematous or swimming pools; follicular, occurs in outbreaks papular, vesicular, or pustular lesions that may involve axillae, buttocks, abdomen, and especially areas occluded by bathing suits; can manifest as tender isolated nodules on palmar or plantar surfaces (the latter designated "Pseudomonas hot-foot syndrome") Red macules on Nonimmune

Earache, sore eyes 145 and/or throat; generally selflimited

Variola

Variola major

Prodrome of fever, 214

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors headache, backache, myalgias; vomiting in 50% of cases

Chapt er

(smallpox)

virus

tongue, palate individuals exposed evolving to to smallpox papules and vesicles; skin macules evolving to papules, then vesicles, then pustules over 1 week, with subsequent lesion crusting; lesions initially appearing on face and spreading centrifugally from trunk to extremities; differs from varicella in that (1) skin lesions in any given area are at same stage of development and (2) there is a prominent distribution of lesions on face and extremities (including palms, soles) as opposed to prominent rash on trunk Erythema rapidly followed by hallmark grouped vesicles that may evolve into pustules; painful lesions that may ulcerate, especially on mucosal surfaces; lesions at site of inoculation: commonly gingivostomatitis for HSV-1 and genital lesions

Primary herpes simplex virus (HSV) infection

HSV

Primary infection Regional most common in lymphadenopathy children and young adults for HSV-1 and in sexually active young adults for HSV-2; no fever in recurrent infection

172

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors

Chapt er

for HSV-2; recurrent disease milder (e.g., herpes labialis does not involve oral mucosa) Disseminated herpesvirus infection Varicella-zoster virus or HSV Generalized Immunosuppressed vesicles that can individuals, eczema evolve to pustules and ulcerations; individual lesions similar for varicella-zoster and HSV. Zoster cutaneous dissemination: >25 lesions extending outside involved dermatome. HSV: extensive, progressive mucocutaneous lesions in some cases; HSV lesions sometimes disseminate in eczematous skin (eczema herpeticum); HSV visceral dissemination may occur with only limited skin lesions Eschar found at Seen in urban site of mite bite; settings; transmitted generalized rash by mouse mites involving face, trunk, extremities; may involve palms and soles; <100 papules and plaques (210 mm); tops of lesions develop vesicles that may evolve into pustules Visceral organ 172, involvement 173, (especially liver) in 376 some cases

Rickettsialpox

Rickettsia akari

Headache, 167 myalgias, regional adenopathy; mild disease

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors Patients with cirrhosis, diabetes, renal failure; exposure by ingestion of contaminated saltwater seafood Usually affects neutropenic patients; occurs in up to 28% of individuals with Pseudomonas bacteremia Hypotension; 50% mortality

Chapt er 149

Disseminated Vibrio vulnificus infection

V. vulnificus

Erythematous lesions evolving into hemorrhagic bullae and then into necrotic ulcers Indurated plaque evolving into hemorrhagic bulla or pustule that sloughs, resulting in eschar formation; erythematous halo; most common in axillary, groin, perianal regions Erythematous, circumscribed areas of edema; occasionally indurated; pruritic or burning; lesions sometimes purpuric; individual lesions lasting up to 5 days

Ecthyma gangrenosum

P. aeruginosa , other gramnegative rods, fungi

Clinical signs of sepsis

145

Urticarial Eruptions Urticarial vasculitis Serum sickness, often due to infection (including hepatitis B viral, enteroviral, parasitic), drugs (including penicillins, sulfonamides, salicylates, barbiturates); connective tissue disease; idiopathic causes Fungi (e.g., candidiasis, histoplasmosis, cryptococcosis, sporotrichosis, coccidioidomycosi s); mycobacteria In serum sickness, occurs 814 days after antigen exposure in nonsensitized individuals; may occur within 36 h in sensitized individuals Malaise, 319d lymphadenopathy, myalgias, arthralgias

Nodular Eruptions Disseminated infection Subcutaneous nodules (up to 3 cm); fluctuance, draining common with mycobacteria; necrotic nodules (extremities, periorbital or nasal regions) common with Aspergillus, Mucor Large, violaceous, Immunocompromise Features vary with d d hosts (i.e., bone organism marrow transplant recipients, patients undergoing chemotherapy, HIVinfected patients, alcoholics)

Erythema Infections (e.g., nodosum (septal streptococcal,

More common in Arthralgias (50%); females 1530 years features vary with

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors associated condition

Chapt er

panniculitis)

fungal, mycobacterial, yersinial); drugs (e.g., sulfas, penicillins, oral contraceptives); sarcoidosis; idiopathic causes Yersinial infection; lymphoproliferativ e disorders; idiopathic causes

nonulcerative, old subcutaneous nodules; exquisitely tender; usually on lower legs but also on upper extremities Tender red or blue edematous nodules giving impression of vesiculation; usually on face, neck, upper extremities; when on lower extremities, may mimic erythema nodosum

Sweet's syndrome (acute febrile neutrophilic dermatosis)

More common in Headache, women and in arthralgias, persons 3060 years leukocytosis old; 20% of cases associated with malignancy (men and women equally affected in this group)

54

Bacillary angiomatosis

Bartonella henselae or Bartonella quintana

Many forms, Usually in HIV including infection erythematous, smooth vascular nodules; friable, exophytic lesions; erythematous plaques (may be dry, scaly); subcutaneous nodules (may be erythematous)

Peliosis of liver and 153 spleen in some cases; lesions may involve multiple organs; bacteremia

Purpuric Eruptions Rocky Mountain spotted fever, rat-bite fever, endocarditise; epidemic typhusg; dengue feverc; human parvovirus B19 infectiong Acute Neisseria meningococcemi meningitidis a d

Initially pink maculopapular lesions evolving into petechiae; petechiae rapidly becoming numerous, sometimes enlarging and becoming

Most common in children, individuals with asplenia or terminal complement component deficiency (C5-C8)

Hypotension, 136 meningitis (sometimes preceded by upper respiratory infection)

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors

Chapt er

vesicular; trunk, extremities most commonly involved; may appear on face, hands, feet; may include purpura fulminans reflecting disseminated intravascular coagulation (see below) Purpura fulminans Severe disseminated intravascular coagulation Large ecchymoses with sharply irregular shapes evolving into hemorrhagic bullae and then into black necrotic lesions Variety of recurrent eruptions, including pink maculopapular; nodular (usually on lower extremities); petechial (sometimes developing vesicular centers); purpuric areas with pale bluegray centers Papules (15 mm) evolving over 12 days into hemorrhagic pustules with gray necrotic centers; hemorrhagic bullae occurring rarely; lesions (usually fewer than 40) distributed peripherally near joints (more commonly on Individuals with sepsis (e.g., involving N. meningitidis), malignancy, or massive trauma; asplenic patients at high risk for sepsis Individuals with complement deficiencies Hypotension 136, 265

Chronic N. meningitidis meningococcemi a

Fevers, sometimes 136 intermittent; arthritis, myalgias, headache

Disseminated gonococcal infection

Neisseria gonorrhoeae

Sexually active Low-grade fever, individuals (more tenosynovitis, often females), some arthritis with complement deficiency

137

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors

Chapt er

upper extremities) Enteroviral petechial rash Usually echovirus Disseminated Often occurs in 9 or petechial lesions outbreaks coxsackievirus A9 (may also be maculopapular, vesicular, or urticarial) Arboviruses and arenaviruses Petechial rash Residence in or travel to endemic areas or other virus exposure Individuals with E. coli O157:H7 gastroenteritis (especially children), cancer chemotherapy, HIV infection, autoimmune diseases; pregnant/postpartu m women Occurs in a wide spectrum of diseases, including connective tissue disease, cryoglobulinemia, malignancy, HenochSchnlein purpura (HSP); more common in children Pharyngitis, headache; aseptic meningitis with echovirus 9 184

Viral hemorrhagic fever

Triad of fever, 189, shock, hemorrhage 190 from mucosa or gastrointestinal tract Fever (not always present), hemolytic anemia, thrombocytopenia, renal dysfunction, neurologic dysfunction; coagulation studies normal 54, 101, 109, 143, 147

Thrombotic thrombocytopeni c purpura/hemolyti c-uremic syndrome

Idiopathic, Escherichia coli O157:H7 (Shiga toxin), drugs

Petechiae

Cutaneous smallvessel vasculitis (leukocytoclastic vasculitis)

Infections (including group A Streptococcus, viral hepatitis), drugs, chemicals, food allergens, idiopathic causes

Palpable purpuric lesions appearing in crops on legs or other dependent areas; may become vesicular or ulcerative; usually resolve over 34 weeks

Fever, malaise, 54 arthralgias, myalgias; systemic vasculitis in some cases; renal, joint, and gastrointestinal involvement commonly seen in HSP

Eruptions with Ulcers and/or Eschars Scrub typhus, rickettsial spotted fevers, rat-bite feverg; rickettsialpox, ecthyma gangrenosumh Tularemia d

Francisella tularensis

Ulceroglandular Exposure to ticks, form: biting flies, infected erythematous, animals tender papule evolves into necrotic, tender ulcer with raised borders; in 35% of cases,

Fever, headache, lymphadenopathy

151

Disease

Etiology

Description

Group Clinical Affected/Epidemio Syndrome logic Factors

Chapt er

eruptions (maculopapular, vesiculopapular, acneiform, urticarial, erythema nodosum, or erythema multiforme) may occur Anthrax Bacillus anthracis Pruritic papule enlarging and evolving into a 1by 3-cm painless ulcer surrounded by vesicles and then developing a central eschar with edema; residual scar Exposure to infected Lymphadenopathy, 214 animals or animal headache products or other exposure to anthrax spores