Under this heading will be considered the skin manifestations of some of the acute infectious diseases which present fairly constant eruptions, as well as some accidental forms. It is a question whether these lesions are toxic in all cases, but it is generally thought that toxins develop in the several processes and cause the appearance of eruptions often similar to the common exanthemata. For a description of the general symptoms of the diseases about to the mentioned, the reader is referred to any text-book on general medicine. While the treatment is more that of the disease, rather than of the eruption, the latter may demand local measures to protect the lesions and to comfort the patient.
ROCKY MOUNTAIN SPOTTED FEVER
This may be described as an actively contagious, endemic, febrile disease occurring from March to July, especially in May and June. Cases are limited to the Rocky Mountain region, particularly Montana and Idaho, and are characterized clinically by continuous fever (101* – 105* F.), severe arthritic and muscular pains, a profuse petechial or purpuric eruption which usually appears on the third or fourth day after the onset on the ankles, wrists, forehead and back, spreading rapidly to other parts of the body. the palms, soles and scalp may be affected in severe cases. The macules, pink or red in color, soon become papules terminating in dark red patches or petechiae which may become large ecchymotic spots. In severe cases these latter may invade the entire cutaneous surface. An icteric macule is often present in addition to the lesions just described. The temperature remains more or less high for ten or twelve days, when the eruption fades and desquamation, most marked on the hands, feet and face, ensues.
Etiology and Pathology. This disease attacks both sexes and all ages but is most common among males between 30 and 40 years of age. Its definite seasonal and endemic occurrences have been noted. The exact cause and intermediary host are unknown but the commonest disseminating agent appears to be the wood-tick (Dermacentor andersoni), for it has been proven that the disease exists in ticks in nature. Whether the organism of Rocky Moutain spotted fever be a protozoon or a bacterium, it is a fact that it is transmitted to man by the bite of the tick and hence the suggestion that some animal host is responsible for the perpetuation of the disease. By a process of elimination the domestic and larger wild animals have been eliminated, and the smaller mammals indigenous to the locality in which the disease exists, such as the ground squirrel, ground hog, rock squirrel, chipmunk, mountain rat and weazel remain as the probable sources of food supply for the ticks. The first named is most prevalent although the other may act as hosts for the virus. The pathological changes are not extreme but are fairly constant. Postmortem findings have been noticed in the skin, spleen, liver, pancreas and kidneys.
Prognosis and Treatment. A high rate of mortality has been noted in individual epidemics, but an average rate would be from 4 to 10 per cent. Prophylactic treatment is most important, and embraces the killing of ticks on cattle, horses, sheep and all other animals in the infected zone. Clearing and burning of the land may be needed and the infected zone. Clearing and burning of the land may be needed and the slaughter of the small animal hosts is most logical. Personal prophylaxis consists in the wearing of tick-proof clothing and a daily search for ticks with their prompt removal. Ricketts has produced a protective serum which may be administered when the bite is noted. This serum, if given early and in large doses, may even be curative. Sodium cacodylate and quinin have been urged, but with only fair results. “Good nursing and symptomatic medication” is the best therapeutic advice.
While little has been said upon the skin complications of this disease, when they are present, they are so fairly constant as to lead to the belief that they are not a mere coincidence. They are mainly of the diffuse scarlatiniform or rubeoliform variety with erythema multiforme and purpura less common. There has been much speculation as to the reason of these eruptions. Theiry suggests three principal theories to explain the relationship between the gonorrheal and the cutaneous manifestations, as follows: (1) a reflex action having its origin in the urethra, and later attacking the skin; 92) a gonorrheal virus; and 930 a mild gonorrheal pyemia. It would seem to me from my own experience that the bacteremia theory is the most plausible.
In possibly 20 per cent. of all cases of typhoid there are no skin manifestations but in the remainder a fairly characteristic eruption makes its appearance on the seventh or eighth day. This may occur, however, as early as the second or as late as the twentieth day. It appears in the form of discrete, rounded, circumscribed, rose-colored macules or maculopapules, which are slightly elevated and not larger than lentil seeds. At first pale red, they later become darker and are rarely petechial. They appear in crops at intervals of from three to four days and persist from three to five days. The entire eruption seldom lasts more than two weeks. The number of spots small, from five to thirty, although exceptionally profuse, and are usually located on the abdomen, thorax and back, though they may extend elsewhere. As has been noted is scarlet fever and measles, small vesicles may develop on the rose spots of typhoid fever and necessarily precede desiccation. Relapses often cause the reappearance of the typhoid spots. Atypical eruptions occasionally occur in the course of typhoid spots. Atypical eruptions occasionally occur in the course of typhoid fever, such as simple, scarlatinoid or morbilliform erythema. These are often drug rashes pure and simples but they may be the result of the absorption of intestinal toxins. Urticaria, purpura, dermatitis gangrenosa or furunculus may rarely occur, while herpes simplex, sudamen and miliaria are more common. Desquamation and atrophic streaks (striae atropicae) have been noted occasionally after typhoid fever.
The eruption in this disease is present in 95 per cent. of all cases and is such a conspicuous and diagnostic feature as to lead to the terms “spotted fever” or “petechial fever.” The eruption usually appears on the fourth of fifth day but may vary from the second to the eleventh day. It is first noted upon the abdomen, thorax and back, sometimes extending to the arms and legs and even to the hands and feet. The face is usually entirely free from the eruption. Two elements are to be noted in this erythema, the so-called “subcuticular mottling” which may be present without the second element, the rose-spots or macules. The latter are pin-head to split-pea in size, pink to rose-red in color, ill-defined and scarcely elevated. Primarily these macules disappear completely upon pressure but gradually, as they become darker, even purplish, pressure will not cause any fading of the discoloration. The dark aspect is caused by extravasation of blood but only a certain proportion of the macules are involved. Petechial spots are more commonly seen on the back and about the flexures of the joints. While simple macules may disappear in a day or two and those showing moderate hemorrhage in five or six days, the deeply colored patches persist for two or three weeks, and all the gradations of color noted in an ordinary black and blue spot will develop. Branny or furfuraceous desquamation ensues. The diagnosis might be confusing when the typical eruption is profuse and coalescing because it will then resemble measles. The early lesions of typhus might simulate those of typhoid. They are, however, less papular, more abundant, and later petechial.
There is no characteristic eruption of this disease. Various forms of erythema such as morbilliform, scarlatiniform, multiform or nodose have occasionally been observed. There may be at times uriticaria, herpes zoster, while herpes facialis and sudamen are more common.
This is an acute epidemic fever, chiefly of the tropical or semitropical countries. At the beginning of the disease there is a transient erythema rarely lasting more than twenty-four hours. A secondary or terminal eruption is far more common and appears on the face, forearms, chest and palms, or may be more general in character. It may resemble scarlet fever, measles or urticaria and lasts from a few hours to three days, followed by various degrees of desquamation. Pruritus is fairly common as the rash fades. Herpes simplex is of common occurrence.
This disease presents no eruption peculiar or constant. Herpes simplex and urticaria occur commonly while a pigmentation of the skin, varying from a pale yellow to a bronze color, may develop, depending upon the degree of anemia and jaundice. Erythemas of various types, purpura and gangrene have been observed in the course of malaria.
EPIDEMIC CEREBROSPINAL MENINGITIS
A petechial eruption was so constant a symptom of this diseases as it first occurred in this country as to lead to the term “spotted fever.” It may be said, however, that at the present time it occurs in a third or less of all cases. This eruption appears about the third day, in the form of pin-head-to-pea-sized dark red or purplish petechiae, which develop into larger ecchymotic spots. The color gradations of the skin subsequently take place. The number of spots is ordinarily small and scattered upon the face, trunk and extremities. Herpes simplex is frequently noted, while sudamen, urticaria and pemphigoid bullae rarely occur.
This rare epidemic disease, chiefly confined to Central Europe, shows marked febrile and nervous symptoms, together with profuse sweating and a typical eruption. The latter is seen about the third or fourth day, often preceded by itching and may be said to occur in the form of morbiliform, scarlatiniform or purpuric erythema. Still another variety which has given the disease its name consists of small aggregations of conical papules which are soon tipped with miliary vesicles. The seat of the eruption is the trunk, extremities, face and even the mucous membrane of the mouth. Desquamation of a furfuraceous or lamellar character ensues after the eruption has lasted several days.
A number of authors have reported erythemas, largely of a toxic character, occurring in the course of or following follicular or septic tonsillitis.
There is no constant or typical eruption present in this disease but sudamen, miliaria and herpes simplex may occur, while urticaria and various erythemas have been noted. Two skin conditions, erythema nodosum and purpura or pelosis rheumatica, are separately considered in this volume, but they are admittedly so often associated with rheumatic might for the sake of completeness be included among the eruptions noted in the course of rheumatic fever.