Maculopapular Rash

Maculopapular Rash: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter

Michael L. O’Dell

Approach

 Rashes are commonly described in a defined set of ways. Macules are skin lesions that are flat and discolored, and up to 1 cm in diameter. Papules are also up to 1 cm, but they are elevated, solid, and well circumscribed. Often, a patient presents with a rash that is a mixture of these two elements, hence the term “maculopapular.” The term maculopapular is subject to disagreement among various diagnosticians (1).

A. Maculopapular rashes can be accompanied by fever, in which case they are generally associated with an infection, particularly a viral infection (Chapter 13.6). Rashes not accompanied by fever often result from allergic reactions, but infection remains common. Rarely, a maculopapular rash is a systemic sign of an underlying malignancy. Table 13.1 contains a partial listing of common causes of maculopapular rash.

B. Serious infectious illnesses, such as meningococcemia, disseminated gonorrhea, and Rocky Mountain spotted fever (RMSF) can present with acute onset of maculopapular rash and fever, often prior to more classic signs (2). The early wheal and flare response of anaphylaxis occasionally presents early in the course with a maculopapular rash, often with palmar or pharygeal itching.

History

A. Seek a history of preceding illness, concurrent fever, or ingestion of medications. A travel history and exposure history are useful.

B. Have the lesions spread? Are they painful, itching, or simply bothersome cosmetically? Have any been on the palms or soles?

C. Are other signs present? Joint swelling can indicate gonococcemia. Headache and confusion can indicate meningococcemia. Difficult breathing can indicate impending collapse from anaphylaxis.

Physical examination

A. Carefully examine the lesions and their distribution.

 1. A rash that is on the face and spreading to the trunk is characteristic of measles or rubella. Many viral illnesses have a predilection for the trunk.

 2. A maculopapular rash occurring on the palms initially should prompt concern about syphilis. RMSF rash also occurs on the palms; usually, however, this rash is not raised until 3 or so days into the course of illness and it is accompanied by purpura on the ankles and wrists. Disseminated gonorrhea lesions are usually on the fingers and quickly become pustular. Meningococcemia can spread widely, but can present as a macule with central petechiae, which progressively becomes nodular.

 B. Conduct a general physical examination. Areas of particular concern are:

 1. Head, eyes, ears, nose, and throat. Although measles is becoming rare, the presence of Koplik’s spots is pathognomic for the illness. A common location for ticks is in the scalp hair, and the discovery of a tick lends support to the diagnosis of RMSF. Rarely, meningococcemia will be a complication of sinusitis, and often it develops following complaints of pharyngitis. Mucous membrane swelling may indicate early anaphylaxis.

 2. Lung examination. Wheezing on examination, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis.

 3. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea (Chapter 10.9). A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.

 4. Joint examination. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis as well.

5. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.

Testing

Tests are generally selected according to the most likely cause of the rash, with a complete blood count (CBC) being the most commonly ordered test.

 A. A CBC is often useful. Increased neutrophils may indicate a bacterial infection; especially when immature neutrophils are present. The CBC is not a sensitive indicator for these infections, however. A relatively normal white blood count does not exclude serious infections (3). Lymphocytosis may indicate a viral infection. Increased eosinophils are occasionally seen with allergic reactions. Myelogenous leukemias generally present with abnormalities on CBC.

 B. Other testing should be performed on the basis of the most likely causes of the rash.

1. Consider syphilis testing in all cases, especially in those patients with palmar rashes.

 2. Consider a smear and culture of any pustules, especially if meningococcemia or gonococcemia is suspected.

 3. Cerebrospinal fluid examination is useful if meningococcemia is suspected; it is usually negative in RMSF, despite headache, back stiffness, and other signs.

Diagnostic assessment

 Although no one key is seen to diagnosing a maculopapular rash, history is the most important key (4). The presence or absence of a fever aids in narrowing the diagnostic field to infectious versus noninfectious causes. The age of the patient aids in determining whether the rash is likely the result of a common viral childhood illness versus an illness more often associated with adults (e.g., syphilis). The exposure history helps in ruling in or out diseases common in selected geographic areas (e.g., RMSF on the United States east coast or dengue fever in Central America). Nevertheless, a careful and thorough physical examination is required as well as judicious use of laboratory testing.

References

1. Schwarzenberger K. The essentials of the complete skin examination. Med Clin North Am 1998;82(5):981–999.

2. Granier S. Recognizing meningococcal disease in primary care: qualitative study of how general practitioners process clinical and contextual information. BMJ 1998;
316(7127):276–279.

3. Kuppermann N. Clinical and hematological features do not reliably identify children with unsuspected meningococcal disease. Pediatrics 1999;103(2):E20.

4. Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996;10(1):101–110.

Pictures

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

More About Skin rash

• Back to disease: Skin rash: Introduction
• Next Book Extract About Skin rash: Vesicular and Bullous Eruptions (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• More Book Extracts: All Online Books for Skin rash

More Medical Textbooks Online about Skin rash

Review other book chapters online related to Skin rash:

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

 » Next page: Vesicular and Bullous Eruptions (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Vesicular and Bullous Eruptions (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• Scaling Rash (Field Guide to Bedside Diagnosis)
• Staphylococcal scalded skin syndrome (Handbook of Diseases)
• Skin, mottled (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
• Skin, clammy (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Tools & Services:

• Bookmark this page
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City