Chickenpox differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Michael Maddaleni, B.S. João André Alves Silva, M.D. [2] Aravind Reddy Kothagadi M.B.B.S[3]

## Overview

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Chickenpox must be differentiated from various rash-causing conditions like Coxsackievirus, Stevens-Johnson syndrome (SJS), measles, rubella, Rocky mountain spotted fever and syphilis.

## Differentiating Chickenpox from other Diseases

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Chickenpox must be differentiated from other diseases presenting with diffuse papulovesicular rash in a febrile patient. The various conditions that should be differentiated from chickenpox include:[1][2][3][4][5][6][7]

### Common conditions to be differentiated from chickenpox:

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Common Conditions | Features

|

Coxsackievirus |

* The most commonly caused disease is the Coxsackie A disease, presenting as hand-foot-mouth disease. It may be asymptomatic or cause mild symptoms. There may be fever and painful blisters in the mouth (herpangina), on the palms and fingers of the hand, or on the soles of the feet. There can also be blisters in the throat or above the tonsils. Adults can also be affected. The rash, which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.

Stevens-Johnson syndrome |

* The symptoms may include fever, sore throat and fatigue. Commonly presents as ulcers and other lesions in the mucous membranes, almost always in the mouth and lips but also in the genital and anal regions. The lesions in the mouth are extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children. A rash measuring about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.

Kawasaki disease |

* Commonly presents with high and persistent fever, red mucous membranes in mouth, "strawberry tongue", swollen lymph nodes and skin rash in early disease, with peeling of the skin of hands, feet and genital area.

Measles |

* Prodrome of high fever, cough, coryza and conjunctivitis, with oral mucosal lesions (Koplik's spots), followed by widespread skin rash.

Syphilis | It commonly presents with gneralized systemic symptoms such as malaise, fatigue, headache and fever. Skin eruptions may be subtle and asymptomatic It is classically described as:

* Non-pruritic bilateral symmetrical mucocutaneous rash
* Non-tender regional lymphadenopathy
* Condylomata lata
* Patchy alopecia

Rubella |

* Commonly presents with a facial rash which then spreads to the trunk and limbs, fading after 3 days, low grade fever, swollen glands, joint pains, headache and conjunctivitis. The rash disappears after a few days with no staining or peeling of the skin. Forchheimer's sign occurs in 20% of cases, and is characterized by small, red papules on the area of the soft palate.

Cytomegalovirus |

* The common symptoms include sore throat, swollen lymph nodes, fever, headache, fatigue, weakness, muscle pain and loss of appetite.

Meningococcemia |

* It commonly presents with rash, petechiae, headache, confusion, and stiff neck, high fever, mental status changes, nausea and vomiting.

Meningitis |

* It commonly presents with headache, nuchal rigidity, fever, petechiae and altered mental status.

Rocky Mountain spotted fever |

* The symptoms may include maculopapular rash, petechial rash, abdominal pain and joint pain.

Molluscum contagiosum |

* The lesions are commonly flesh-colored, dome-shaped and pearly in appearance. They are often 1-5 millimeters in diameter, with an umblicated center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further infection or scarring. In about 10% of the cases, eczema develops around the lesions. They may occasionally be complicated by secondary bacterial infections.

Mononucleosis |

* Common symptoms include low-grade fever without chills, sore throat, white patches on tonsils and back of the throat, muscle weakness and sometime extreme fatigue, tender lymphadenopathy, petechial hemorrhage and skin rash

### Less common conditions to be differentiated from chickenpox:

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Less Common Diseases | Features

|

Atypical measles |

* The symptoms commonly begin about 7-14 days after infection and present as fever, cough, coryza and conjunctivitis. Observation of Koplik's spots is also a characteristic finding in measles.

Parvovirus B19 |

* The rash of fifth disease is typically described as "slapped cheeks", with erythema across the cheeks and sparing the nasolabial folds, forehead, and mouth.

Rickettsial pox |

* The first symptom is commonly a bump formed by a mite-bite, eventually resulting in a black, crusty scab. Many of the symptoms are flu-like including fever, chills, weakness and muscle pain but the most distinctive symptom is the rash that breaks out, with a generalized distribution.

Toxic erythema |

* It is a common rash in infants, with clustered and vesicular appearance.

Monkeypox |

* The presentation is similar to smallpox, although it is often a milder form, with fever, headache, myalgia, back pain, swollen lymph nodes, a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a papular rash, often first on the face. The lesions usually develop through several stages before crusting and falling off.

Rat-bite fever |

* It commonly presents with fever, chills, open sore at the site of the bite and rash, which may show red or purple plaques.

Scarlet fever |

* It commonly includes fever, punctate red macules on the hard and soft palate and uvula (Forchheimer's spots), bright red tongue with a "strawberry" appearance, sore throat and headache and lymphadenopathy.

### Differentiating chickenpox infection in immunocompromised host

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Varicella Zoster virus infection is common among immunocompromised patients who are at high risk for other fungal, bacterial, and viral infections. It should be differentiated from the following diseases, which may present as confusion, fever and headache in immunocompromised patients:

Disease  | Differentiating signs and symptoms  | Differentiating tests

|
|

CNS lymphoma[8] |

* Patient is immunocompetent
* Focal symptoms indicative of a mass lesion
* Seizure

* Single solitary ring enhancing lesion on CT or MRI

Disseminated tuberculosis[9] |

* Prior history of residence in an endemic area
* Chronic cough, weight loss, hemoptysis

* PCR of CSF for tuberculosis
* Mycobacterial culture of CSF
* Brain biopsy for acid-fast bacilli staining
* Culture and acid stain positive for acid-fast bacilli
* CXR shows cavitations

Aspergillosis[10] |

* Pulmonary lesions in addition to CNS lesions
* Symptoms may include cough, chest pain, and hemoptysis

* CSF fungal culture, galactomannan

Cryptococcosis |

* Symptoms include cough, chest pain, and hemoptysis

* Cryptococcal antigen from CSF and serum
* CSF fungal culture

Chagas disease[11] |

* History of residence in Central or South America
* Acute infection is rarely symptomatic
* Encephalitis or focal brain lesions
* Myocarditis
* Chronic infections in immunocompromised patients develop into encephalitis with necrotic brain lesions causing a mass effect

* Trypanosoma cruzi in blood, tissue, or CSF, PCR of tissue or body fluids, and serologic tests

CMV infection[12] |

* Most common CNS opportunistic infection in AIDS patients
* Presents with encephalitis, retinitis, progressive myelitis, or polyradiculitis
* In disseminated disease, it involves both the liver and kidneys

* Brain CT/MRI/biopsy: location of lesions is usually near the brain stem or periventricular areas
* PCR of CSF with detectable virus is diagnostic
* Brain biopsy with + staining for CMV or evidence of owl's eyes is also diagnostic, but it is rarely performed because of the location of brain lesions

HSV infection[13] |

* Seizures, headache, confusion and/or urinary retention can be seen in disseminated disease, which usually affects only the immunocompromised or acute infections
* In pregnant women, it may be associated with concurrent genital/oral lesions; can be spread to the neonate during acute infection in the mother, or via viral shedding in the birth canal
* Neonatal HSV can range from localized skin infections to encephalitis, pneumonitis, and disseminated disease

* Brain CT/MRI/biopsy: location of lesions is usually the medial temporal lobe or the orbital surface of the frontal lobe.
* PCR of CSF with detectable virus is diagnostic

Varicella Zoster infection[14] |

* Multifocal involvement has subacute course, usually only in immunosuppressed, with headache, fever, focal deficits, and seizures
* Unifocal involvement is more typically seen in immunocompetent hosts, occurring after contralateral cranial nerve herpes zoster, with mental status changes, TIAs, and stroke
* Disseminated varicella zoster virus can occur in adults during primary infection, presenting with pneumonitis and/or hepatitis
* Disease is a vasculopathy with hemorrhage and stroke

* PCR of CSF with detectable virus is diagnostic

Brain abscess[15][16] |

* Associated with sinusitis (abutting the sinuses) or with bacteremia
* Signs and symptoms includes fever and necrotizing brain lesions with mass effect

* CSF culture or culture of brain abscess

Progressive multifocal leukoencephalopathy[17] |

* Symptoms are often more insidious in onset and progress over months. Symptoms include progressive weakness, poor coordination, with gradual slowing of mental function. Only seen in the immunosuppressed. Rarely associated with fever or other systemic symptoms

* PCR of CSF for JC virus
* Biopsy reveals white matter lesions and not well-circumscribed lesions.

### Oral lesions to be differentiated from chicken pox:

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Oral lesions caused by chickenpox must be differentiated from other diseases presenting with pain and blistering within the mouth (gingivostomatitis and glossitis). The differentials include:

Disease  | Presentation  | Risk Factors  | Diagnosis  | Affected Organ Systems  | Important features  | Picture

|
|
|
|
|
|

|  |  |
Coxsackie virus |

* Fever
* Sores in the mouth
* Rash with blisters
* Myalgia

* Pregnancy
* immunodeficiency

* History and Physical exam
* Throat swabs
* Swabs from the lesion
* Tzanck test

* Mucuos membrane
* Skin

* Symptomatic treatment

Chicken pox |

* Conjunctival symptoms:

* Conjunctival injection
* Cloudy cornea

* Catarrhal symptoms:

* Rhinorrhea
* Coughing
* Sneezing

* Characteristic spots on the trunk appearing in two or three waves
* Itching

* Pregnancy
* Premature infants born to susceptible mothers
* All infants born at less than 28 weeks gestation or who weigh ≤1000 grams
* Immunocompromised

* History and physical exam
* PCR to detect VZV in skin lesions (vesicles, scabs, maculopapular lesions)

* Oral cavity
* Skin

* Sodium bicarbonate in baths or antihistamines for itching
* Paracetamol (acetaminophen) for fever
* Prednisolone is contraindicated

Measles |

* Fever
* Rash
* Cough
* Coryza (runny nose)
* Conjunctivitis (pink eye)
* Malaise
* Koplick spots in mouth

* Unvaccinated individuals[18][19]
* Crowded and/or unsanitary conditions
* Traveling to less developed and developing countries
* Immunocompromized
* Winter and spring seasons
* Born after 1956 and never fully vaccinated
* Health care workers

* History and examination
* PCR for Measles-specific IgM antibody
* PCR for Measles RNA

* Oral cavity
* Skin
* Respiratory tract
* Eyes
* Throat

* Caused by Morbillivirus
* Primary site of infection is the respiratory epithelium of the nasopharynx
* Transmitted in respiratory secretions, via aerosol droplets containing virus particles

Herpangina |

* Sudden fever
* Sore throat and dysphagia\- These can occur several hours(up to 24 hours), before the appearance of the enanthem.
* Vomiting
* Abdominal pain
* Myalgia
* Headache
* Pharyngeal lesions

* Attendance at a kindergarten/child care center
* Contact with herpangina cases
* Residence in rural areas
* Overcrowding
* Poor hygiene
* Low socioeconomic status

* Clincial diagnosis
* Pharyngeal viral and bacterial cultures can be taken to exclude HSV infection and streptococcal pharyngitis.

* Skin
* Oral Cavity

* Characteristic exanthem- Punctate macule which evolve over a period of 24 hours to 2-4mm erythematous papules which vesiculate, and then centrally ulcerate.
* The lesions are usually small in number, and evolve rapidly. The lesions are seen more commonly on the soft palate and uvula. The lesions can also be seen on the tonsils, posterior pharyngeal wall and the buccal mucosa.

|  Erythema, vesicles and ulcerating lesions in herpangina
Primary herpetic gingivostomatitis[20] |

* Pin-head vesicles rupture to form painful irregular ulcerations covered by yellow-grey membrane
* Severe pain
* Submandibular lymphadenopathy
* Halitosis
* It involves buccal mucosa, tongue, posterior pharynx, and gingival and palatal mucosa

* Direct contact
* HIV infection

* Tzanck test demonstrates multinucleated epithelial giant cells[21]
* Viral culture is the gold standard for diagnosis
* Direct immunofluorescence

* Oral cavity
* Mucous membranes

* Ulcers are common on lips, gums, throat, front of tongue, inside of the cheeks and roof of the mouth
* Treatment is with antiviral agents such as Valacyclovir and Famciclovir

Oral Candidiasis |

* Dysphagia or odynophagia
* White patches on the mouth and tongue

|  |

* Clinical diagnosis
* Confirmatory tests rarely needed

| Localized candidiasis

* Oral and esophageal candidasis
* Candida vulvovaginitis
* Chronic mucocutaneous candidiasis

Invasive candidasis

* Candidaemia
* Candida endocarditis
* Candida osteoarticular disease

* Oral candidiaisis is a benign self limiting disease unless accompanied by immunosuppression.

| Tongue infected with oral candidiasis - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg

Disease  | Presentation  | Risk Factors  | Diagnosis  | Affected Organ Systems  | Important features  | Picture

|
|
|
|
|
|

Diseases predominantly affecting the oral cavity  |  |  |  |
Oral Candidiasis |

* Dysphagia or odynophagia
* White patches on the mouth and tongue

* Newborn babies

* Denture users

* Poorly controlled diabetes

* As a side effect of medication, most commonly having taken antibiotics. Inhaled corticosteroids for the treatment of lung conditions (e.g, asthma or COPD) may also result in oral candidiasis which may be reduced by regularly rinsing the mouth with water after taking the medication.

* People with poor nutrition, specifically vitamin A, iron and folate deficiencies.

* People with an immune deficiency (e.g. as a result of AIDS/HIV or chemotherapy treatment).

* Women undergoing hormonal changes, like pregnancy or those on birth control pills.

* Organ transplantation patients

* Clinical diagnosis
* Confirmatory tests rarely needed

| Localized candidiasis

* Oral and esophageal candidasis
* Candida vulvovaginitis
* Chronic mucocutaneous candidiasis

Invasive candidasis

* Candidaemia
* Candida endocarditis
* Candida osteoarticular disease

* Oral candidiaisis is a benign self limiting disease unless accompanied by immunosuppression.

| Tongue infected with oral candidiasis - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg
Herpes simplex oral lesions |

* Fever
* Sore throat
* Painful ulcers

* Stress
* Recent URTI
* Female sex

* Physical examination
* Viral culture
* Tzanck smear

* Orofacial Infection
* Anogenital Infection
* Ocular Infection
* Herpes Encephalitis
* Neonatal Herpes
* Herpetic Whitlow
* Herpes Gladiatorum

* The symptoms of primary HSV infection generally resolve within two weeks

| Oral herpes simplex infection - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=19051042.jpg
Aphthous ulcers |

* Painful, red spot or bump that develops into an open ulcer

* Being a female
* Between the ages of 10-40
* Family history of aphthous ulcers

* Physical examination
* Diagnosis of exclusion

* Oral cavity

* Self-limiting , Pain decreases in 7 to 10 days, with complete healing in 1 to 3 weeks

| Apthous ulcer on the lower surface of the tongue - By Ebarruda - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=7903358
Squamous cell carcinoma |

* Non healing ulcer, nodule, indurated plaque or mass
* May involve skin, lips, inside the mouth, throat or esophagus

* Chronic sun or UV exposure
* Fair skin
* Elderly age (>45 yrs)
* Male sex
* Smoking

* Physical exam
* Biopsy

* Oral Cavity
* Floor of mouth
* Lateral tongue
* Throat
* Esophagus

* Malignant
* Can spread to TMJ
* Some times associated with leukoplakia

| Squamous cell carcinoma - By Luca Pastore, Maria Luisa Fiorella, Raffaele Fiorella, Lorenzo Lo Muzio - http://www.plosmedicine.org/article/showImageLarge.action?uri=info:doi/10.1371/journal.pmed.0050212.g001, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=15252632
Leukoplakia |

* White leathery spots on the mucous membranes of the tongue and inside of the mouth
* Lateral borders of tongue

* Atypical Tobacco use
* Chronic irritation
* Immunodeficiency
* Bloodroot (sanguinaria)

* Physical exam
* Diagnosis of exclusion
* Biopsy

* Vulvar lesions occur independent of oral lesions

* Associated with HIV
* Persistant white spots
* Benign but can progress to carcinoma after almost 10 years
* Oral proliferative verrucous leukoplakia is an aggressive sub type with multiple lesions and higher conversion to warts or carcinoma[22]

| Leukoplakia - By Aitor III - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9873087
Melanoma |

* A lesion with ABCD
* Asymmetry
* Border irregularity
* Color variation
* Diameter changes
* Bleeding from the lesion

* UV radiations
* Genetic predisposition
* Old age
* Male gender
* Family or personal history of melanoma
* Multiple benign or atypical nevi

* ABCD characteristics
* Bleeding or ulceration may show malignancy
* Serum LDH may be elevated in case of malignancy
* Biopsy

* Can metastasize
* All UV radiation or sun exposed areas can be effected independently
* 1-2 to hundreds of granules

* Neural crest cell derivative
* Development begins with disruption of nevus growth control
* Progression involves MAPK/ERK pathway
* N-RAS or BRAF oncogene also involved

| Oral melanoma - By Emmanouil K Symvoulakis, Dionysios E Kyrmizakis, Emmanouil I Drivas, Anastassios V Koutsopoulos, Stylianos G Malandrakis, Charalambos E Skoulakis and John G Bizakis - Symvoulakis et al. Head & Face Medicine 2006 2:7 doi:10.1186/1746-160X-2-7 (Open Access), [1], CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=9839811
Fordyce spots |

* Rice-like granules or spots
* Small, painless, raised, pale, red or white
* 1 to 3 mm in diameter

* Greasy skin types
* Some rheumatic disorders
* Hereditary nonpolyposis colorectal cancer
* Lower gingiva (gums)
* Vestibular mucosa

* Physical exam
* Small keratin-filled pseudocysts
* May be seen on incidental mucosal biopsy
* Biopsy not done for them primarily

* Oral cavity
* Vermilion border of the lips
* Oral mucosa of the upper lip
* Buccal mucosa in the commissural region often bilaterally
* Genitals

* Benign neoplasms with sebaceous features
* Visible sebaceous glands
* No surrounding mucosal change
* Several adjacent glands may coalesce into a larger cauliflower-like cluster

| Fordyce spots - Por Perene - Obra do próprio, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19772899
Burning mouth syndrome |

* Burning or tingling on the lips, tongue, or entire mouth

* Nutritional deficiencies
* Chronic anxiety or depression
* Diabetes type 2
* Menopause
* Oral thrush or dry mouth, or damaged nerves transmitting taste
* Female gender
* Menopause

* Presentation
* Physical exam

* Oral cavity

* Pain typically is low in the morning and builds up over the day
* Low dosages of benzodiazepines, tricyclic antidepressants or anticonvulsants may be effective

Torus palatinus |

* Bony growth on midline of the hard palate
* Nodular mass covered with normal mucosa

* Genetic predisposition
* Autosomal dominant

* Physical exam
* Types
* Flat tori
* Spindle tori
* Nodular tori
* Lobular tori

* Hard palate

* More common in Asian and Inuit populations
* Twice more common in females
* Repeated trauma can cause bleeding
* Surgery may be required in symptomatic

| Torus palatinus - By Photo taken by dozenist, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=846591
Diseases involving oral cavity and other organ systems |  |  |
Behcet's disease |

* Painful mouth sores
* Acne like skin lesions
* Headache, fever, poor balance, disorientation
* Abdominal pain, diarrhea or bleeding
* Uveitis
* Joint swelling and joint pain
* Genital sores wit pain and scaring
* Aneurysms

* Over active immune system

* Physical examination

* Mouth
* Genitals
* GIT
* Eye
* Joints
* Skin
* Vascular system
* Brain

* Outbreaks of exaggerated inflammation
* Affects smaller blood vessels

| Behcet's disease - By Ahmet Altiner MD, Rajni Mandal MD - http://dermatology.cdlib.org/1611/articles/18_2009-10-20/2.jpg, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17863021
Crohn's disease |

* Chronic, episodic diarrhea or constipation
* Abdominal pain
* Vomiting
* Weight loss or weight gain

* Smoking
* Whites and European Jews
* Hormonal contraception
* Diets high in microparticles, sweet, fatty or refined foods
* Industrialized country

* Typical history and symptoms
* Skip lesions on biopsy
* Anti-Saccharomyces cerevisiae antibodies (ASCA)
* Anti-neutrophil cytoplasmic antibodies (ANCA)

* Eyes
* Joints
* Skin

* May lead to
* Obstructions
* Abscesses
* Free perforation
* Hemorrhage

Agranulocytosis |

* Fever or chills
* Frequent infections
* Unusual redness, pain, or swelling around a wound
* Mouth ulcers
* Abdominal pain
* Burning sensation when urinating
* Sore throat

* Medications[23]
* Cytotoxic chemotherapy
* Hematologic malignancies
* Autoimmune disorders

* Neutropenia <100 cells per micro litre
* Eosinopenia
* Basopenia

* Oral cavity
* Skin
* GIT
* Urinary system
* Conjunctiva

* Immunocompromization
* Types
* Drug-induced
* Malignant
* Autoimmune

Syphilis[24] |

* Chancre
* Regional lymphadenopathy

* Multiple sexual partners
* Illicit drug use
* Unprotected sex
* Men who have sex with men
* Residence in highly prevalent areas
* HIV infection
* Presence of other STIs
* Previous history of STIs
* Intravenous drug use

* Darkfield microscopy
* Non treponemal tests like VDRL and RPR test)
* Treponemal testsFTA-ABS tests, (TP-PA) assay, enzyme immunoassays, and chemiluminescence immunoassays)

* Oral cavity
* Penis
* Cervix
* Labia
* Anal canal
* Rectum
* CNS
* CVS

* Primary syphilis
* Chancre
* Secondary syphilis
* Condylomata lata
* Latent syphilis
* Asymptomatic
* Tertiary syphilis
* Gummas
* Neurosyphilis

| oral syphilis - By CDC/Susan Lindsley - http://phil.cdc.gov/phil_images/20021114/34/PHIL_2385_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=2134349
Coxsackie virus |

* Fever
* Sores in the mouth
* Rash with blisters
* Aches

* Pregnancy
* immunodeficiency

* History and Physical exam
* Throat swabs
* Swabs from the lesion
* Tzanck test

* Oral cavity
* Skin

* Symptomatic treatment

| Coxsackie virus stomatitis - Adapted from Dermatology Atlas.[25]
Chicken pox |

* Conjunctival symptoms
* Catarrhal symptoms
* Characteristic spots on the trunk appearing in two or three waves
* Itching

* Pregnancy
* Premature infants born to susceptible mothers
* All infants born at less than 28 weeks gestation or who weigh =1000 grams
* Immunocompromised

* History and physical exam
* PCR to detect VZV in skin lesions (vesicles, scabs, maculopapular lesions)

* Oral cavity
* Skin

* Sodium bicarbonate in baths or antihistamines for itching
* Paracetamol (acetaminophen) for fever
* Prednisolone is contraindicated

| Chickenpox - By James Heilman, MD - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=52872565
Measles |

* Fever
* Rash
* Cough
* Coryza (runny nose)
* Conjunctivitis (pink eye)
* Malaise
* Koplick spots in mouth

* Unvaccinated individuals[18][19]
* Crowded and/or unsanitary conditions
* Traveling to less developed and developing countries
* Immunocompromized
* Winter and spring seasons
* Born after 1956 and never fully vaccinated
* Health care workers

* History and examination
* PCR for Measles-specific IgM antibody
* PCR for Measles RNA

* Oral cavity
* Skin
* Respiratory tract
* Eyes
* Throat

* Caused by Morbillivirus
* Primary site of infection is the respiratory epithelium of the nasopharynx
* Transmitted in respiratory secretions, via aerosol droplets containing virus particles

| Koplick spots (Measles) - By CDC - http://phil.cdc.gov/PHIL_Images/20040908/4f54ee8f0e5f49f58aaa30c1bc6413ba/6111_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=824483

## References

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2. ↑ Mehta N, Chen KK, Kroumpouzos G (2016). "Skin disease in pregnancy: The approach of the obstetric medicine physician". Clin Dermatol. 34 (3): 320–6. doi:10.1016/j.clindermatol.2016.02.003. PMID 27265069.CS1 maint: Multiple names: authors list (link)
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6. ↑ Kimura U, Yokoyama K, Hiruma M, Kano R, Takamori K, Suga Y (2015). "Tinea faciei caused by Trichophyton mentagrophytes (molecular type Arthroderma benhamiae ) mimics impetigo : a case report and literature review of cases in Japan". Med Mycol J. 56 (1): E1–5. doi:10.3314/mmj.56.E1. PMID 25855021.CS1 maint: Multiple names: authors list (link)
7. ↑ CEDEF (2012). "[Item 87--Mucocutaneous bacterial infections]". Ann Dermatol Venereol. 139 (11 Suppl): A32–9. doi:10.1016/j.annder.2012.01.002. PMID 23176858.
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9. ↑ von Reyn CF, Kimambo S, Mtei L, Arbeit RD, Maro I, Bakari M, Matee M, Lahey T, Adams LV, Black W, Mackenzie T, Lyimo J, Tvaroha S, Waddell R, Kreiswirth B, Horsburgh CR, Pallangyo K (2011). "Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality". Int. J. Tuberc. Lung Dis. 15 (8): 1087–92. doi:10.5588/ijtld.10.0517. PMID 21740673.
10. ↑ Latgé JP (1999). "Aspergillus fumigatus and aspergillosis". Clin. Microbiol. Rev. 12 (2): 310–50. PMC 88920. PMID 10194462.
11. ↑ Rassi A, Rassi A, Marin-Neto JA (2010). "Chagas disease". Lancet. 375 (9723): 1388–402. doi:10.1016/S0140-6736(10)60061-X. PMID 20399979.
12. ↑ Emery VC (2001). "Investigation of CMV disease in immunocompromised patients". J. Clin. Pathol. 54 (2): 84–8. PMC 1731357. PMID 11215290.
13. ↑ Bustamante CI, Wade JC (1991). "Herpes simplex virus infection in the immunocompromised cancer patient". J. Clin. Oncol. 9 (10): 1903–15. doi:10.1200/JCO.1991.9.10.1903. PMID 1919640.
14. ↑ Hambleton S (2005). "Chickenpox". Curr. Opin. Infect. Dis. 18 (3): 235–40. PMID 15864101.
15. ↑ Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR (2013). "Brain abscess: Current management". J Neurosci Rural Pract. 4 (Suppl 1): S67–81. doi:10.4103/0976-3147.116472. PMC 3808066. PMID 24174804.
16. ↑ Patel K, Clifford DB (2014). "Bacterial brain abscess". Neurohospitalist. 4 (4): 196–204. doi:10.1177/1941874414540684. PMC 4212419. PMID 25360205.
17. ↑ Tan CS, Koralnik IJ (2010). "Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis". Lancet Neurol. 9 (4): 425–37. doi:10.1016/S1474-4422(10)70040-5. PMC 2880524. PMID 20298966.
18. ↑ 18.0 18.1 Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE (2000). "Individual and community risks of measles and pertussis associated with personal exemptions to immunization". JAMA. 284 (24): 3145–50. PMID 11135778.CS1 maint: Multiple names: authors list (link)
19. ↑ 19.0 19.1 Ratnam S, West R, Gadag V, Williams B, Oates E (1996). "Immunity against measles in school-aged children: implications for measles revaccination strategies". Can J Public Health. 87 (6): 407–10. PMID 9009400.CS1 maint: Multiple names: authors list (link)
20. ↑ Kolokotronis, A.; Doumas, S. (2006). "Herpes simplex virus infection, with particular reference to the progression and complications of primary herpetic gingivostomatitis". Clinical Microbiology and Infection. 12 (3): 202–211. doi:10.1111/j.1469-0691.2005.01336.x. ISSN 1198-743X.
21. ↑ Chauvin PJ, Ajar AH (2002). "Acute herpetic gingivostomatitis in adults: a review of 13 cases, including diagnosis and management". J Can Dent Assoc. 68 (4): 247–51. PMID 12626280.
22. ↑ Ann M. Gillenwater, Nadarajah Vigneswaran, Hanadi Fatani, Pierre Saintigny & Adel K. El-Naggar (2013). "Proliferative verrucous leukoplakia (PVL): a review of an elusive pathologic entity!". Advances in anatomic pathology. 20 (6): 416–423. doi:10.1097/PAP.0b013e3182a92df1. PMID 24113312. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
23. ↑ Andrès E, Zimmer J, Affenberger S, Federici L, Alt M, Maloisel F. (2006). "Idiosyncratic drug-induced agranulocytosis: Update of an old disorder". Eur J Intern Med. 17 (8): 529–35. Text "pmid 17142169" ignored (help)CS1 maint: Multiple names: authors list (link)
24. ↑ title="By Internet Archive Book Images [No restrictions], via Wikimedia Commons" href="https://commons.wikimedia.org/wiki/File:A_manual_of_syphilis_and_the_venereal_diseases,_(1900)_(14595882378).jpg"
25. ↑ "Dermatology Atlas".