Erythema marginatum: Difference between revisions
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==Background== | ==Background== | ||
Erythema marginatum | [[File:960px-Erythema marginatum.jpg|thumb|Classic Erythema marginatum rash]] | ||
*A rare, non-pruritic rash that is one of the major Jones criteria for [[acute rheumatic fever]] (ARF) | |||
*Strongly associated with post-streptococcal autoimmune responses, particularly in children and adolescents | |||
*Though uncommon in the ED, its recognition is important because it may be an early or subtle clue to a potentially serious systemic illness, especially when accompanied by joint pain, fever, or cardiac involvement. | |||
==Clinical Features== | ==Clinical Features== | ||
Appearance | ===Appearance=== | ||
* Pink to red, serpiginous or annular macules or patches | * Pink to red, serpiginous or annular macules or patches | ||
* Central clearing, with raised margins | * Central clearing, with raised margins | ||
* May coalesce into polycyclic shapes | * May coalesce into polycyclic shapes | ||
Distribution | |||
===Distribution=== | |||
* Typically found on trunk and proximal limbs | * Typically found on trunk and proximal limbs | ||
* Spares the face | * Spares the face | ||
Characteristics | |||
===Characteristics=== | |||
* Transient (lesions may appear and disappear over hours) | * Transient (lesions may appear and disappear over hours) | ||
* Non-pruritic, often unnoticed by the patient | * Non-pruritic, often unnoticed by the patient | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
* Urticaria (usually pruritic and shorter-lived lesions) | * Urticaria (usually pruritic and shorter-lived lesions) | ||
* Tinea corporis (scaly border; longer duration) | * Tinea corporis (scaly border; longer duration) | ||
* Erythema multiforme (target lesions; mucosal involvement) | * Erythema multiforme (target lesions; mucosal involvement) | ||
* Erythema migrans (Lyme disease; often has history of tick exposure) | * Erythema migrans (Lyme disease; often has history of tick exposure) | ||
* Erythema annulare centrifugum | * Erythema annulare centrifugum | ||
* Pityriasis rosea (typically has herald patch, follows cleavage lines) | * Pityriasis rosea (typically has herald patch, follows cleavage lines) | ||
* Systemic lupus erythematosus (may produce annular lesions) | * Systemic lupus erythematosus (may produce annular lesions) | ||
* Drug eruptions | * Drug eruptions | ||
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===Workup=== | ===Workup=== | ||
* Rapid strep test or throat culture | * Rapid strep test or throat culture | ||
* Anti-streptolysin O (ASO) or anti-DNase B titers | * Anti-streptolysin O (ASO) or anti-DNase B titers | ||
* CBC (may show leukocytosis) | * CBC (may show leukocytosis) | ||
* ESR/CRP (typically elevated in ARF) | * ESR/CRP (typically elevated in ARF) | ||
* | * [[ECG]] (look for PR prolongation) | ||
* [[Echocardiogram]] if there are signs/symptoms of carditis | |||
* | |||
===Diagnosis=== | ===Diagnosis=== | ||
Diagnosis | Diagnosis is clinical and often supportive in the context of other signs of [[acute rheumatic fever]]. Confirm diagnosis of ARF using revised [[Jones criteria]]: | ||
* Major criteria: migratory arthritis, carditis, chorea, erythema marginatum, subcutaneous nodules | * Major criteria: migratory arthritis, carditis, chorea, erythema marginatum, subcutaneous nodules | ||
* Minor criteria: fever, arthralgia, elevated ESR/CRP, prolonged PR interval | * Minor criteria: fever, arthralgia, elevated ESR/CRP, prolonged PR interval | ||
* | * A diagnosis of ARF typically requires 2 major or 1 major + 2 minor criteria, plus evidence of recent group A Streptococcus infection. | ||
A diagnosis of ARF typically requires 2 major or 1 major + 2 minor criteria, plus evidence of recent group A Streptococcus infection. | |||
==Management== | ==Management== | ||
* Treat underlying acute rheumatic fever: | * Treat underlying acute rheumatic fever: | ||
**[[Penicillins|Penicillin]] or other antibiotics to eradicate streptococcal infection | |||
** [[Penicillins|Penicillin]] or other antibiotics to eradicate streptococcal infection | |||
** [[Aspirin]] or [[Nonsteroidal anti-inflammatory drugs|NSAIDs]] for arthritis | ** [[Aspirin]] or [[Nonsteroidal anti-inflammatory drugs|NSAIDs]] for arthritis | ||
** [[Corticosteroids]] in severe carditis | ** [[Corticosteroids]] in severe carditis | ||
* Skin lesions themselves do not require direct treatment, as they are self-limited | * Skin lesions themselves do not require direct treatment, as they are self-limited | ||
* Patient and family education about recurrence prevention and long-term prophylaxis | * Patient and family education about recurrence prevention and long-term prophylaxis | ||
==Disposition== | ==Disposition== | ||
Discharge | ===Discharge=== | ||
*If well-appearing, hemodynamically stable, and has a plan for follow-up with cardiology and primary care for rheumatic fever management | |||
Admit | ===Admit=== | ||
* There is suspected or confirmed carditis | * There is suspected or confirmed carditis | ||
* Patient is febrile, toxic, or has signs of systemic involvement | * Patient is febrile, toxic, or has signs of systemic involvement | ||
* Requires workup and treatment initiation for suspected acute rheumatic fever | * Requires workup and treatment initiation for suspected [[acute rheumatic fever]] | ||
==See Also== | ==See Also== | ||
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==External Links== | ==External Links== | ||
[https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html CDC – Acute Rheumatic Fever] | *[https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html CDC – Acute Rheumatic Fever] | ||
*[https://www.ahajournals.org/doi/10.1161/cir.0000000000000205 American Heart Association – Jones Criteria Summary] | |||
[https://www.ahajournals.org/doi/10.1161/cir.0000000000000205 American Heart Association – Jones Criteria Summary] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
Latest revision as of 23:12, 10 December 2025
Background
- A rare, non-pruritic rash that is one of the major Jones criteria for acute rheumatic fever (ARF)
- Strongly associated with post-streptococcal autoimmune responses, particularly in children and adolescents
- Though uncommon in the ED, its recognition is important because it may be an early or subtle clue to a potentially serious systemic illness, especially when accompanied by joint pain, fever, or cardiac involvement.
Clinical Features
Appearance
- Pink to red, serpiginous or annular macules or patches
- Central clearing, with raised margins
- May coalesce into polycyclic shapes
Distribution
- Typically found on trunk and proximal limbs
- Spares the face
Characteristics
- Transient (lesions may appear and disappear over hours)
- Non-pruritic, often unnoticed by the patient
- Usually occurs early in the course of ARF
Differential Diagnosis
- Urticaria (usually pruritic and shorter-lived lesions)
- Tinea corporis (scaly border; longer duration)
- Erythema multiforme (target lesions; mucosal involvement)
- Erythema migrans (Lyme disease; often has history of tick exposure)
- Erythema annulare centrifugum
- Pityriasis rosea (typically has herald patch, follows cleavage lines)
- Systemic lupus erythematosus (may produce annular lesions)
- Drug eruptions
Evaluation
Workup
- Rapid strep test or throat culture
- Anti-streptolysin O (ASO) or anti-DNase B titers
- CBC (may show leukocytosis)
- ESR/CRP (typically elevated in ARF)
- ECG (look for PR prolongation)
- Echocardiogram if there are signs/symptoms of carditis
Diagnosis
Diagnosis is clinical and often supportive in the context of other signs of acute rheumatic fever. Confirm diagnosis of ARF using revised Jones criteria:
- Major criteria: migratory arthritis, carditis, chorea, erythema marginatum, subcutaneous nodules
- Minor criteria: fever, arthralgia, elevated ESR/CRP, prolonged PR interval
- A diagnosis of ARF typically requires 2 major or 1 major + 2 minor criteria, plus evidence of recent group A Streptococcus infection.
Management
- Treat underlying acute rheumatic fever:
- Penicillin or other antibiotics to eradicate streptococcal infection
- Aspirin or NSAIDs for arthritis
- Corticosteroids in severe carditis
- Skin lesions themselves do not require direct treatment, as they are self-limited
- Patient and family education about recurrence prevention and long-term prophylaxis
Disposition
Discharge
- If well-appearing, hemodynamically stable, and has a plan for follow-up with cardiology and primary care for rheumatic fever management
Admit
- There is suspected or confirmed carditis
- Patient is febrile, toxic, or has signs of systemic involvement
- Requires workup and treatment initiation for suspected acute rheumatic fever