Serious skin signs in sick patients

Overview

In emergency medicine and critical care it is essential to be able to recognise skin signs that signify serious disease, and be able to consider the likely causes.

Signs and causes

Generalized red rash with fever

• Viral exanthems
• Rickettsial exanthems
• Drug eruptions
• Bacterial infections with toxin production

Generalized red rash with blisters and prominent mouth lesions

• Erythema multiforme (major)
• Toxic epidermal necrolysis
• Pemphigus
• Bullous pemphigoid
• Drug eruptions

Generalized red rash with pustules

• Pustular psoriasis (von Zumbusch)
• Drug eruptions

Generalized rash with vesicles

• Disseminated herpes simplex
• Generalized herpes zoster
• Varicella
• Drug eruptions

Generalized red rash with scaling over whole body

• Exfoliative erythroderma

Generalized wheals and soft tissue swelling

• Urticaria and angioedema

Generalized purpura

• Thrombocytopenia
• Purpura fulminans
• Drug eruptions

Generalized purpura that can be palpated

• Vasculitis
• Bacterial endocarditis

Multiple skin infarcts

• Meningococcemia
• Gonococcemia
• Disseminated intravascular coagulopathy

Localized skin infarcts

• Calciphylaxis
• Atherosclerosis obliterans
• Atheroembolization
• Warfarin necrosis
• Antiphospholipid antibody syndrome

Facial inflammatory edema with fever

• Erysipelas
• Lupus erythematosus

References and Links

• Wolff K, Johnson RA. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Fifth Edition, McGraw Hill, 2009.

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

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