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Toxic Exanthems in the Adult Population

      Abstract

      Frequently the internist is confronted with the nonspecific exanthematous eruption. While often a sign of a benign and self-limiting process, an exanthem also might herald the development of a more severe systemic syndrome. Infections, immune-mediated processes, drug reactions, a neoplasm, and familial syndromes with poor prognoses might all manifest initially with an exanthem. A thorough history and complete physical examination should be performed on all patients who present with an exanthem. Characterization of the exanthem morphology, other physical examination findings, and review of systems can help guide laboratory testing and ensure prompt diagnosis and early treatment of potentially life-threatening conditions. This article provides a brief overview of the conditions that must be considered in the evaluation of an ill patient with an exanthem.

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      References

        • Sereni F.
        • Sereni L.P.
        Exanthematous infectious diseases in pediatrics: curiosities from the old pediatric literature.
        Pediatr Infect Dis J. 2004; 23: 350-354
        • Manders S.M.
        Toxin-mediated streptococcal and staphylococcal disease.
        J Am Acad Dermatol. 1998; 39: 383-398
        • Drage L.
        Life-threatening rashes: dermatologic signs of four infectious diseases.
        Mayo Clin Proc. 1999; 74: 68-72
        • Habif T.P.
        Clinical Dermatology: A Color Guide to Diagnosis and Therapy.
        4th edn. Mosby, New York2004
        • Ramos-e-Silva M.
        • Pereira A.L.
        Life-threatening eruptions due to infectious agents.
        Clin Dermatol. 2005; 23: 148-156
        • Wolf J.E.
        • Rabinowitz L.G.
        Streptococcal toxic shock-like syndrome.
        Arch Dermatol. 1995; 131: 73-77
        • Finkelstein S.
        • Hyland R.H.
        Toxic shock syndrome as the acquired immune deficiency syndrome (AIDS)-defining diagnosis.
        Chest. 1993; 104: 950-951
        • Darenberg J.
        • Söderquist B.
        • Normark B.H.
        • Norrby-Teglund A.
        Differences in potency of intravenous polyspecific immunoglobulin G against streptococcal and staphylococcal superantigens: implications for therapy of toxic shock syndrome.
        Clin Infect Dis. 2004; 38: 836-842
        • Cone L.A.
        • Woodard D.R.
        • Byrd R.G.
        • et al.
        A recalcitrant, erythematous, desquamating disorder associated with toxin-producing staphylococci in patients with aids.
        J Infect Dis. 1992; 165: 638-643
        • Cribier B.
        • Peimont Y.
        • Grosshans E.
        Staphylococcal scalded skin syndrome in adults.
        J Am Acad Dermatol. 1994; 30: 319-324
        • Gemmell C.G.
        Staphylococcal scalded skin syndrome.
        J Med Microbiol. 1995; 43: 318-327
        • Farrell A.M.
        • Ross J.S.
        • Umaskankar S.
        • Bunker C.B.
        Staphylococcal scalded skin syndrome in an HIV-1 seropositive man.
        Br J Dermatol. 1995; 134: 962-965
        • Brown E.J.
        The molecular basis of streptococcal toxic shock syndrome.
        N Engl J Med. 2004; 350: 2093-2094
        • Darenberg J.
        • Ihendyane N.
        • Sjölin J.
        • et al.
        Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial.
        Clin Infect Dis. 2003; 37: 333-340
        • Masters E.J.
        • Olson G.S.
        • Weiner S.J.
        • Paddock C.D.
        Rocky Mountain spotted fever: a clinician's dilemma.
        Arch Intern Med. 2003; 163: 769-774
        • Lacz N.L.
        • Schwartz R.A.
        • Kapila R.
        Rocky Mountain spotted fever.
        J Eur Acad Dermatol Venereol. 2006; 20: 411-417
        • National Center for Immunization and Respiratory Disease
        Typhoid Fever.
        (Accessed September 30, 2008)
        • Hoffner R.J.
        • Slaven E.
        • Perez J.
        Emergency department presentations of typhoid fever.
        J Emerg Med. 2000; 19: 317-320
        • Bialecki C.
        • Feder H.M.
        • Grant-Kels J.M.
        The six classical exanthems: a review and update.
        J Am Acad Dermatol. 1989; 21: 891-903
        • Muñoz J.
        • Alonso D.
        • Vilella A.
        • Naniche D.
        Measles in travelers: are we aware enough?.
        J Travel Med. 2008; 15: 124-125
        • Centers for Disease Control and Prevention (CDC)
        Update: Measles—United States, January-July 2008.
        MMWR Morb Mortal Wkly Rep. 2008; 57: 893-896
        • Carneiro S.C.S.
        • Cestari T.
        • Allen S.H.
        • Ramos e-Silva M.
        Viral exanthems in the tropics.
        Clin Dermatol. 2007; 25: 212-220
        • Controlprevention of rubella
        evaluation and management of suspected outbreaks, rubella in pregnant women, and surveillance for congenital rubella syndrome.
        MMWR Recomm Rep. 2001; 50: 1-23
        • Waza K.
        • Inoue K.
        • Matsumura S.
        Symptoms associated with parvovirus B19 infection in adults: a pilot study.
        Intern Med. 2007; 46: 1975-1978
        • Ikediobi N.I.
        • Tyring S.K.
        Cutaneous manifestations of Epstein-Barr virus infection.
        Dermatol Clin. 2002; 20: 283-289
        • Renn C.N.
        • Straff W.
        • Dorfmüller A.
        • et al.
        Amoxicillin-induced exanthema in young adults with infectious mononucleosis: demonstration of drug-specific lymphocyte reactivity.
        Br J Dermatol. 2002; 147: 1166-1170
        • Jappe U.
        Amoxicillin-induced exanthema in patients with infectious mononucleosis: allergy or transient immunostimulation?.
        Allergy. 2007; 62: 1474-1475
        • Garman M.E.
        • Tyring S.K.
        The cutaneous manifestations of HIV infection.
        Dermatol Clin. 2002; 20: 193-208
        • Zalla M.J.
        • Su W.P.D.
        • Fransway A.F.
        Dermatologic manifestations of human immunodeficiency virus infection.
        Mayo Clin Proc. 1992; 67: 1089-1108
        • Hulsebosch H.J.
        • Claessen F.A.P.
        • van Ginkel C.J.W.
        Human immunodeficiency virus exanthema.
        J Am Acad Dermatol. 1990; 23: 483-486
        • Kobayashi S.
        • Segawa S.
        • Kawashima M.
        • et al.
        A case of symptomatic primary HIV infection.
        J Dermatol. 2005; 32: 137-142
        • Mert A.
        • Ozaras R.
        • Tabak F.
        • et al.
        Fever of unknown origin: a review of 20 patients with Adult-onset Still's disease.
        Clin Rheumatol. 2003; 22: 89-93
        • Yang C.C.
        • Lee J.Y.
        • Liu J.F.
        • Ho C.L.
        Adult-onset Still's disease with persistent skin eruption and fatal respiratory failure in a Taiwanese woman.
        Eur J Dermatol. 2006; 16: 593-594
        • Slovis B.S.
        • Eyler A.E.
        A 33-year-old man with pharyngitis, transient rash, and multiorgan system failure.
        Chest. 2007; 132: 1080-1083
        • Hong Y.H.
        • Lee C.K.
        A case of adult onset Still's disease with systemic inflammatory response syndrome complicated by fatal status epilepticus.
        Rheumatol Int. 2008; 28: 931-933
        • Sève P.
        • Stankovic K.
        • Smail A.
        • et al.
        Adult Kawasaki disease: report of two cases and literature review.
        Semin Arthritis Rheum. 2005; 34: 785-792
        • Karoui K.
        • Servais A.
        • Fadel F.
        Acute renal failure and febrile rash—infectious or not?.
        Nephrol Dial Transplant. 2007; 22: 949-951
        • Johnson M.L.
        • Farmer E.R.
        Graft-versus-host reactions in dermatology.
        J Am Acad Dermatol. 1998; 38: 369-396
        • Whalen J.G.
        • Jukic D.M.
        • English III, J.C.
        Rash and pancytopenia as initial manifestations of acute graft-versus-host disease after liver transplantation.
        J Am Acad Dermatol. 2005; 52: 908-912
        • Schmuth M.
        • Vogel W.
        • Weinlich G.
        Cutaneous lesions as the presenting sign of acute graft-versus-host disease following liver transplantation.
        Br J Dermatol. 1999; 141: 901-904
        • Aractingi S.
        • Chosidow O.
        Cutaneous graft-versus-host disease.
        Arch Dermatol. 1998; 134: 602-612
        • Häusermann P.
        • Walter R.B.
        • Halter J.
        Cutaneous graft-versus-host disease: a guide for the dermatologist.
        Dermatology. 2008; 216: 287-304
        • Roujeau J.C.
        • Stern R.S.
        Severe adverse cutaneous reactions to drugs.
        N Engl J Med. 1994; 331: 1272-1285
        • Wolf R.
        • Orion E.
        • Marcos B.
        • Matz H.
        Life-threatening acute adverse cutaneous drug reactions.
        Clin Dermatol. 2005; 23: 171-181
        • Bastuji-Garin S.
        • Fouchard N.
        • Bertocchi M.
        • et al.
        SCORTEN: a severity-of-illness score for toxic epidermal necrolysis.
        J Invest Dermatol. 2000; 115: 149-153
        • Ghislain P.D.
        • Roujeau J.C.
        Treatment of severe drug reactions: Stevens-Johnson syndrome, toxic epidermal necrolysis and hypersensitivity syndrome.
        Dermatol Online J. 2002; 8: 5
        • Roujeau J.C.
        Clinical heterogeneity of drug hypersensitivity.
        Toxicology. 2005; 209: 123-129
        • Bachot N.
        • Roujeau J.C.
        Differential diagnosis of severe cutaneous drug eruptions.
        Am J Clin Dermatol. 2003; 4: 561-572
        • Martel P.
        • Laroche L.
        • Courville P.
        Cutaneous involvement in patients with angioimmunoblastic lymphadenopathy with dysproteinemia: a clinical, immunohistological, and molecular analysis.
        Arch Dermatol. 2000; 136: 881-886
        • Farasat S.
        • Aksentijevich I.
        • Toro J.R.
        Autoinflammatory diseases: clinical and genetic advances.
        Arch Dermatol. 2008; 144: 392-402
        • Toro J.R.
        • Aksentijevich I.
        • Hull K.
        • et al.
        Tumor necrosis factor receptor-associated periodic syndrome.
        Arch Dermatol. 2000; 136: 1487-1494
        • Kanazawa N.
        • Furukawa F.
        Autoinflammatory syndromes with a dermatological perspective.
        J Dermatol. 2007; 34: 601-618