Table 5.

Severe infections with skin manifestations

Pathogen/disease entity	Epidemiologic clues	Skin findings
Bacterial
Rickettsia rickettsii/rocky mountain spotted fever	Late spring to early fall. Travel to United States predominantly southeast of Rocky Mountains, Central America, South America	Typically appears between day 3 and 6 of illness. Erythematous macules on wrists and ankles that spread centripetally, but spare the face. Includes palms/soles. May also see petechiae that develop into purpura
Francisella tularensis/tularemia	Rabbit, tick, or deer fly exposure. Travel to US, Eastern Europe, China, Japan	No skin findings in most severe typhoidal form. In ulceroglandular form, can see ulcer at site of tick bite with associated regional lymphadenopathy
Yersinia pestis/bubonic plague	Flea or rodent exposure.Travel to Southeast Asia, Western/Southwestern United States, South America, predominantly Southeast Africa including Madagascar, but also Libya and Algeria	Bubonic: inoculation site may have pustule or ulcer. Painful regional lymphadenopathy with suppuration and discharge from lymph nodes. Septicemic: vesicles, carbuncles, petechiae, and purpura all possible
Neisseria meningitidis/meningococcemia	Worldwide distribution, most cases in winter and spring. Patients with asplenia or terminal complement deficiency	Petechiae that may progress to retiform purpura and ischemic necrosis. Bullous hemorrhagic lesions also possible
Mycobacterial
Mycobacterium tuberculosis/miliary TB	Travel or residence in TB endemic areas	Small blue/red papules topped by vesicles that develop umbilication and crust formation
Viral
Variola major virus/Smallpox	Agent of bioterror	Synchronous firm, deep-seated, well-circumscribed vesiculo-pustules. Car involve palms and soles, though tend to be concentrated on face/limbs
Varicella zoster virus	Immunocompromised hosts more likely to have disseminated disease	Multi-dermatome asynchronous vesicles, can have hemorrhagic and purpuric lesions
Fungal/mold
Aspergillus	Immunocompromised hosts	Necrotic papulonodules, nodules
Candidiasis	Immunocompromised hosts	Multiple possibilities including ecthyma gangrenosum, firm erythematous papules or nodules with pale or hemorrhagic centers
Mucormycoses	Immunocompromised hosts	Ecthyma gangrenosum, necrotic papulonodules, hemorrhagic crusts
Cryptococcus	Bird dropping exposure	Umbilicated papules (similar in appearance to molluscum contagiosum)
Histoplasmosis	Travel to US, Central or South America, Africa. Bird dropping exposure, activities that aerosolize soil, chicken coop exposure, spelunkers	Variable: Oral ulcers, mucocutaneous erosions or ulcers, erythematous papules or nodules with scale or crust
Blastomycosis	Travel to US or Canada with spore inhalation from soil	Papulopustules and verrucous plagues with scale/crust. Advanced disease may mimic pyoderma gangrenosum
Trichosporon	Immunocompromised hosts	Papulovesicles, purpura, necrotic papulonodules
Fusariosis	Immunocompromised hosts	Often has a periungual focus. Multiple possibilities: umbilicated or necrotic papules, pustules, subcutaneous nodules, ecthyma gangrenosum
Penicilliosis	Southeast Asia, China	Umbilicated papules (similar in appearance to molluscum contagiosum). Can also see necrotic nodules, acneiform lesions.Typically involves face, trunk, arms
Parasitic
Strongyioides stercoraiis	Worldwide, particularly tropical areas. Can occur decades after exposure if host becomes immunosuppressed	Localized perianal urticarial possible, but can involve thighs, abdomen (larva currens). Can also see retiform purpura