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) | * ECG (look for PR prolongation) | ||
* Echocardiogram if there are signs/symptoms of carditis | * Echocardiogram if there are signs/symptoms of carditis | ||
===Diagnosis=== | ===Diagnosis=== | ||
Diagnosis of erythema marginatum is clinical and often supportive in the context of other signs of [[Acute rheumatic fever|acute rheumatic fever]]. Confirm diagnosis of ARF using revised [[Jones criteria]]: | Diagnosis of erythema marginatum is clinical and often supportive in the context of other signs of [[Acute rheumatic fever|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 | ||
Revision as of 23:10, 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 of erythema marginatum 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