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Kawasaki Disease (see Chapter 101 Rheumatologic Emergencies )
Kawasaki disease can present with a wide variety of rashes, including
morbilliform and urticarial. Conjunctivitis, when present, is unique in that it is
nonexudative with limbal sparing. Other dermatologic manifestations include red
cracked lips, strawberry tongue, and erythematous oropharynx, and erythema,
swelling, and/or induration of peripheral extremities.
The most commonly associated rash is a generalized exanthem with raised
erythematous plaques; however, the rash may also present with an erythematous
maculopapular, morbilliform, scarlatiniform, or erythema marginatum–like
pattern. Peeling in the diaper/groin area is also frequently observed early. The
exanthem may be fleeting or persist for 2 to 3 days. During the later stages of the
acute phase, periungual desquamation and peeling of the palms, soles, or perineal
area develop.
Measles (Rubeola)
Measles was one of the most common viral exanthems before the measles
vaccine. It is now on the rise again because of increased opting out of
vaccinations for children. The incubation period is 10 to 14 days after direct
contact with droplets from an infected person. In its classic form, measles has a
highly characteristic natural history. Two to 3 days after the onset of the
prodromal symptoms of cough, coryza, conjunctivitis, and fever, Koplik spots
occur in the mouth, followed 12 to 24 hours later by the cutaneous exanthem.
Most typically, Koplik spots appear as pinpoint white lesions on a red base on the
buccal mucosa adjacent to the molars; however, they may be seen on any of the
mucosal surfaces of the oral cavity except the tongue.
The measles exanthem begins on the head as reddish maculopapules and
spreads caudally during the next 4 to 5 days. Within 1 to 2 days of its appearance,
the discrete maculopapular lesions coalesce to produce the confluent phase of the
rash. Hence, within 2 to 3 days of onset, the rash on the face becomes confluent,
whereas the rash on the lower extremities still consists of individual
maculopapules. Modified measles occurs in children who have received serum
immunoglobulin after exposure to measles. Measles may still occur, but the

incubation period may be delayed up to 21 days. The symptoms, although
following the usual progression, will be milder. A faint rash and mild febrile
illness may occur 7 to 10 days after immunization with the live attenuated
measles vaccine.
Rocky Mountain Spotted Fever