Where in the World Did You Get That Rash?

The challenge to diagnose cutaneous eruptions and lesions in patients who have spent time in foreign countries is increasingly common. With the advent of increased global travel, foreign adoptions, immigration, and refugee seekers, rashes that were once relegated to the realm of the exotic and likely to show up in a tropical diseases clinic may now present to a general pediatrician. Furthermore, the pediatric traveler is at increased risk for dermatoses. (1) It behooves the practitioner to be aware of these skin findings, to be able to recognize them and distinguish them from other skin conditions.After completing this article, readers should be able to:Along with the current COVID-19 (coronavirus 2019) outbreak, this review article draws attention to the fact that international travel can introduce unexpected diseases throughout the world.Joseph A. Zenel, MDEditor-in-ChiefIn patients with a travel history, there are different frameworks for organizing an approach to rashes. One approach is to consider the infectious agents present commonly in the countries of exposure. However, this approach will miss many more mundane infections, noninfectious causes of skin disease, and perhaps disease unrelated to travel but occurring coincidentally with travel.Perhaps the most practical approach to skin lesions in those with a travel history is to consider the morphology of the presenting skin findings and to consider the infectious (both tropical and cosmopolitan) as well as noninfectious (both travel-related and non–travel-related) causes of similar skin features. Considering rashes by morphologic pattern allows for a practical starting point for diagnosis. Herein, 7 morphologic patterns are examined in detail with approaches to diagnoses within each group (Table 1).The focus will be on 1) the approach to patients with skin lesions and a history of time spent in other locations, 2) review of the common eruptions seen in such patients and how to distinguish these eruptions from those unrelated to travel, and 3) some key eruptions that should not be missed in the approach to these patients.Much of the data available on diseases in patients who have been to foreign destinations has been collected internationally by the GeoSentinel Surveillance Network. Cutaneous diseases are the third most common group behind respiratory signs and symptoms, diarrhea, and fever in travel-related diseases. (1)(2)(3) Studies of the pediatric traveler are limited, although they compose part of the larger studies on diseases in returning travelers. Lederman et al (1) found that returning travelers with a dermatologic diagnosis had greater odds of being younger than 18 years. As such, data from broader populations are discussed herein.We, therefore, determined a profile of common dermatologic problems in travelers, both tropical and cosmopolitan, from GeoSentinel data (Table 2).There are potential pitfalls when assessing skin disease in the returning traveler. When a patient with a travel history presents with skin lesions or a rash, it is tempting to assume that an exotic infection was picked up during travel. This narrowed approach will often neglect many other possible—although perhaps more mundane—infections that can be acquired during travel. Travel may also be unrelated to an infection incubating before travel but presenting coincidentally with travel. A much broader approach to the patient’s history will ensure attention to other diagnostic considerations. A second pitfall may be to ignore remote infectious exposures for which a latency period causes the skin disease to develop months or years after the exposure. One needs to take into consideration travel-related skin disease in such cases to appropriately acquire the patient’s history.Figure 1 presents a diagnostic framework with which to consider cutaneous disease in the returning traveler.Fever is rarely associated with skin findings. (1) However, fever and morbilliform rash in the returning traveler should alert the physician to consider arboviruses such as dengue and typhoid. Emerging entities to also consider are chikungunya and Zika viruses, and vaccine-preventable cosmopolitan illnesses such as measles.Dengue fever (DF) is one of the most frequent causes of febrile illness among pediatric travelers returning from southeast Asia, Latin America, and the Caribbean. (3) It is transmitted to humans by the mosquito Aedes aegypti. There are 4 serotypes, and immunity after infection is distinct to the serotype. (8)The incubation period of DF ranges from 3 to 14 days, with clinical features including retro-orbital pain, myalgia, arthralgia, and adenopathy. (8) Cutaneous manifestations are found in 50% to 82% of DF-positive cases but may vary in presentation among different age groups. (9) Transient flushing erythema of the face, neck, and chest occurs within the first 24 to 48 hours of fever. (8) Three to 5 days later, a generalized maculopapular rash appears resembling “white islands in a sea of red” as small islets of skin are spared. (8) This confluent rash starts on the extremities and moves centrally, tends to spare the face, and is not usually associated with pruritus. (9) Hemorrhagic manifestations such as petechiae/purpura and a positive tourniquet test result may also be present (Fig 2). (10)Diagnosis is with viral isolation, viral polymerase chain reaction (PCR) positivity, or paired serology (acute and convalescent-phase serum), and management is supportive with fluid therapy. Mosquito avoidance strategies can aid in prevention. (8)Chikungunya is another Aedes mosquito-borne disease, most commonly reported in travelers returning from the Caribbean, particularly Haiti and south central Asia. (11)With an incubation period ranging from 1 to 12 days, the infection presents with acute-onset fever, headache, arthralgia, lymphadenopathy, and a rash that is reported in 30% to 60% of children. (1) This skin eruption initially presents as a flushing erythema of the face, neck, and trunk, which then progresses into a generalized, nonpruritic, morbilliform rash with islands of spared skin 3 to 5 days later (Fig 3). (8)(10) Of note, the cutaneous manifestations of chikungunya vary across different age groups. The initial flushing of the skin has been followed by vesiculobullous lesions in some infants. (12) Chikungunya fever is oftentimes hard to distinguish clinically from the initial stages of DF. (3) With that said, arthralgia is more severe in patients with chikungunya fever, whereas myalgia is the more prominent feature in DF. (13)Laboratory diagnosis is through reverse transcriptase PCR (RT-PCR) and serologic testing; treatment is supportive, and mosquito avoidance is recommended. (12)Zika virus infection is a major global health concern due to recent outbreaks in South and Central America, along with the Caribbean. (14)It is transmitted to humans mainly through A aegypti mosquitoes. Zika virus has an incubation period of 3 to 12 days, and its clinical manifestations include arthralgia, nonpurulent conjunctivitis, and headache. Skin findings are present in 90% of patients. (10)(14) Fever is mild if present. Along with hyperemic conjunctivitis, pruritic micropapular exanthema has been reported as a unique mucocutaneous finding in Zika virus infection. Skin eruption starts on the trunk and descends to the lower body. Petechiae are also found on the palate. (10)Infection can be confirmed with RT-PCR, and treatment is supportive. (10)(14)Typhoid fever is caused by the bacterium Salmonella typhi, which is shed in the stool during the illness and in asymptomatic carriers. It is transmitted through the fecal-oral route. Typhoid fever was found to be the most common cause of fever in children returning from Asia. (15)The incubation period for S typhi can range from 3 to 60 days. (16) Clinical features are prolonged high fever, abdominal pain, and classic cutaneous “rose spots.” These are discrete pink and blanchable macules 2 to 4 mm in diameter appearing on the trunk and abdomen during the second week of the illness (Fig 4). These nonpruritic rose spots last 2 to 5 days and disappear without scarring. (17)(18)Blood culture is the main diagnostic method. (16) Third-generation cephalosporins or azithromycin are first-line treatments. (19) Hand hygiene is one preventive strategy, and a vaccination is available, although its benefit may wane over time, necessitating a booster. (20)Measles remains a major disease in developing countries and is increasingly reported in industrialized countries due to a decline in vaccination rates. (21) It is found mainly in Asia, as well as in Africa and Europe. Children who are not sufficiently vaccinated are at increased risk for contracting this viral illness. (21)Measles virus is mainly transmitted by respiratory droplets and has an incubation period of 7 to 21 days. A classic tetrad of prodromal features includes cough, coryza, conjunctivitis, and Koplik spots. (21) Koplik spots are gray-white papules on an erythematous base and usually appear on the buccal mucosa (Fig 5). (22) A nonpruritic rash develops 2 to 4 days after the onset of symptoms. Erythematous macules and papules first appear on the face and descend toward the extremities, lasting 4 to 7 days (Fig 6). (21) The exanthem is around sebaceous glands and hair follicles and can be mildly hemorrhagic. Patients are infectious from 4 days before to 4 days after rash onset. (22)Laboratory diagnosis is made through serologic testing and RT-PCR of the throat swab and urine. (23) In addition to treating measles symptomatically and treating the complications, there are some therapies that may be helpful. Vaccine administered within 72 hours of contact may limit disease development. The same is true of postexposure intramuscular immune serum globulin provided within 6 days of contact. This can be used for high-risk patients. Adjunct vitamin A treatment reduces blindness and death rates. (24)Of note, the previously mentioned infections could present with a feverless exanthema, and the differential diagnosis of a patient with a morbilliform rash is essentially the same whether or not fever is present.Drug eruption can be a non–travel-related cause of a maculopapular rash. It can be difficult to recognize exanthematous drug eruptions at times because many patients who have nonspecific infectious symptoms are given reaction and other clinical findings can drug eruptions from infectious This is an not to the diagnosis but also to a patient from being as a drug if in fact the rash is due to the infectious an an infection and drug treatment can an by a patient by virus is such an (Fig is to that drug eruptions can and be in the differential diagnosis in patient presenting with skin findings when have been disease is a of of The diagnostic include a fever lasting for at 5 days and 4 of the clinical a rash, conjunctivitis, lymphadenopathy, and in the morbilliform eruption is the most common of the over the trunk and extremities, including the occurs (Fig to the diagnostic of should distinguish it from a travel-related rash. is but of the risk of throughout 2 and the most commonly reported dermatologic illnesses in children in addition to although the present as a and not as a to consider in the differential diagnosis of eruptions include and is a skin caused by of the or It is among the in the pediatric traveler returning from the Caribbean. 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