Skin Signs of Systemic Disease

Abstract

The skin can be the window to systemic diseases. The presenting cutaneous symptoms and signs will lead the clinician to a more focused differential diagnosis and thus aid in the ordering of laboratory tests. In some cases, for example, lymphoma, the skin biopsy is diagnostic.

Chapter Contents
Fever and Rash
Itching Patient
Skin Signs of AIDS
Skin Signs of Cancer
Sun Sensitivity

Fever and Rash

Key Points

1.

Characterize the rash to limit the differential diagnosis
2.

Do laboratory tests based on the history and physical examination

A wide spectrum of diseases can present with fever and rash, including infections, drug reactions (e.g., DRESS; Fig 23.1 ), collagen vascular diseases, and vasculitis. These causes are listed in Table 23.1 , according to the primary cutaneous lesions: macules and papules, purpura, nodules and plaques, vesicles and bullae, and pustules. Some of these diseases (e.g., meningococcemia; Fig. 23.2 ) are life threatening and require prompt diagnosis and treatment.

Table 23.1

Fever and Rash

Macules and papules (erythematous rashes)

●

Infections
- ●
  
  Viral
  - Measles (rubella, rubeola)
  - Adenovirus
  - Echovirus
  - Infectious mononucleosis
  - Human immunodeficiency virus (HIV)
  - West Nile
  - Ebola
  - Chikungunya
  - Zika
- ●
  
  Bacterial
  - Staphylococcus – toxic shock syndrome
  - Streptococcus – erysipelas, rheumatic and scarlet fever
  - Typhoid fever
  - Typhus – endemic
  - Rat-bite fever
- ●
  
  Treponemal
  - Erythema migrans (Lyme disease)
  - Secondary syphilis
- ●
  
  Fungal
  - Cryptococcosis
●

Drug reaction with eosinophilia and systemic symptoms (DRESS)
●

Connective tissue disease
- Systemic lupus erythematosus
- Dermatomyositis
- Juvenile rheumatoid arthritis
- Adult Still disease
●

Erythema multiforme
●

Kawasaki syndrome
●

Tumor necrosis factor receptor-associated periodic syndrome (TRAPS)
●

Familial Mediterranean fever
●

Hyperimmunoglobulinemia D syndrome (HIDS)
●

Interferonopathies

Purpura

●

Infections
- ●
  
  Viral
  - Ebola
  - Enterovirus
  - Dengue
  - Hepatitis
- ●
  
  Bacterial
  - Gonococcemia
  - Meningococcemia
  - Pseudomonas septicemia
  - Bacterial endocarditis
- ●
  
  Rickettsial
  - Typhus – epidemic
  - Rocky Mountain spotted fever
- ●
  
  Ehrlichiosis

- ●
  
  Fungal
  - Candidal septicemia
- ●
  
  Drug reaction
- ●
  
  Vasculitis
- ●
  
  Connective tissue disease
  - Systemic lupus erythematosus
  - Rheumatoid arthritis
- ●
  
  Thrombotic thrombocytopenic purpura

Nodules and plaques

●

Infections
- ●
  
  Bacterial
  - Tuberculosis
- ●
  
  Fungal
  - Histoplasmosis
  - Blastomycosis
  - Coccidioidomycosis
●

Lymphoma
●

Erythema nodosum
●

Sweet syndrome

Vesicles and bullae

●

Infections
- ●
  
  Viral
  - Herpes simplex (primary, disseminated)
  - Herpes zoster (disseminated)
  - Coxsackie (hand, foot, and mouth syndrome)
  - Varicella
  - Monkeypox
  - Orf
  - Smallpox
- ●
  
  Rickettsial
  - Rickettsialpox
- ●
  
  Bacterial
  - Staphylococcal scalded skin syndrome
  - Drug reaction (toxic epidermal necrolysis—TEN)
●

Erythema multiforme

Pustules

●

Infections
- ●
  
  Viral
  - Herpes simplex and zoster
  - Varicella
- ●
  
  Treponemal
  - Congenital syphilis
- ●
  
  Bacterial
  - Gonococcemia
- ●
  
  Fungal
  - Candidal septicemia
  - Blastomycosis
●

Drug eruption (acute generalized exanthematous pustulosis-AGEP)
●

Pustular psoriasis