Deadly Rashes Not to Miss in the ED

Alexandra Murray, OMSII


July 01, 2013

There are a variety of dermatological complaints that present to the emergency department resulting in approximately 5-8% of all ED visits.[1] While some of these cutaneous presentations are relatively benign, such as in cases of atopic dermatitis, urticaria, eczema and psoriasis, there are multiple dermatological emergencies that can be fatal without rapid identification and treatment. Highlighted below are the characteristic skin manifestations of seven of the most common, acutely deadly diseases. Each of the listed diseases has a high risk of mortality within 48 hours if left untreated.[2,3,4]

Rocky Mountain Spotted Fever: The rash begins on day three to four of the infection, typically on the wrists and ankles, before spreading to the palms and soles. The rash subsequently spreads centrally to involve the proximal extremities and trunk. Gangrenous areas may eventually develop on fingers, toes, nose, ears, scrotum and vulva.[1,2,3]

Figure 1.

Photo Courtesy of Wikimedia Commons: Rocky Mountain Spotted Fever.

Neisseria Meningitis: The rash first appears as an asymptomatic petechial eruption that begins over the ankles and wrists and may progress to involve almost any part of the body. Over a few hours the rash evolves into a pathognomonic palpable purpura with gunmetal gray necrotic centers.[2,3,4]

Figure 2.

Neisseria Meningitis. © Copyright 2007 – 2011 Auckland Regional Public Health Service, ADHB. All rights reserved.

Staphylococcal Toxic Shock Syndrome: Patients present with an explosive onset of diffuse, red, sandpaper-like, macular erythroderma followed by desquamation (especially of the hands and feet within 5-14 days). Appears as an exaggerated sunburn.[1,2,3]

Figure 3.

Staphylococcal Toxic Shock Syndrome. Photo Courtesy of Wikispaces : vdsstream VDS.

Streptococcal Toxic Shock Syndrome: Patients present with rash in less than 10% of cases. The rash is commonly seen in the setting of an invasive soft tissue infection. There may be violacious, hemorrhagic bullae with surrounding erythema, and edema sometimes compounded by subtle evidence of soft tissue necrosis.[2,3,4]

Figure 4.

Streptococcal Toxic Shock Syndrome. Photo Courtesy of Journal of Medical Case Reports.

Toxic Epidermal Necrolysis (TEN)/ Lyell Syndrome: Rash begins with non-pruritic, 1-2cm, urticarial plaques, which rapidly progress to coalescing bullae that rupture to leave red, denuded integument that is extremely painful to light touch. Mucosal erosions are also seen involving the oral, genital, conjunctiva and nasal mucosa accompanied by widespread epidermal sloughing.[2,3]

Figure 5.

Photo Courtesy of Wikimedia Commons: Toxic-Epidermal-Necrolysis.

Necrotizing Fasciitis: Patients initially present with areas of erythematous skin and a few blisters that are extremely painful to light touch. Within 24 hours the skin appears dusky blue in color with numerous bullae, the roofs of which slough with mild pressure.[2,3]

Figure 6.

Photo Courtesy of Wikimedia Commons: Necrotizing Fasciitis Left Leg.

Erythema Multiforme Major (EM)/ Stevens Johnson Syndrome (SJS): EM minor (mild form) presents with a highly regular, circular, wheal-like erythematous papule or plaque. EM major (severe form) presents with Stevens Johnson Syndrome (SJS) in the presence of multi organ system illness. SJS rash is characterized by widespread, non-pruritic, painful vesiculobullous lesions and erosions of the mucous membranes. [2,3]

Figure 7.

Photo Courtesy of Wikimedia Commons: Stevens-Johnson-Syndrome.