Chickenpox differential diagnosis

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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

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

Different rash-like conditions can be confused with chickenpox and are thus included in its differential diagnosis. The various conditions that should be differentiated from chickenpox include:[1][2][3][4][5][6][7]

Common conditions to be differentiated from chickenpox:

Common Conditions Features
Coxsackievirus
  • The most commonly caused disease is the Coxsackie A disease, presenting as hand, foot and mouth disease. It may be asymptomatic or cause mild symptoms, or it may produce 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 ulcers and other lesions in the mucous membranes, almost always in the mouth and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children. A rash of round lesions 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
Measles
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:
Rubella
Cytomegalovirus
Meningococcemia
Meningitis
Rocky Mountain spotted fever
Molluscum contagiosum
  • The lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled 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

Less common conditions to be differentiated from chickenpox:

Less Common Diseases Features
Atypical 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
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

The following table is a list of differential diagnosis of oral lesions presenting similar to chicken pox:


Disease Presentation Risk Factors Diagnosis Affected Organ Systems Important features Picture
Coxsackie virus
  • Symptomatic treatment
Hand-foot-and-mouth disease
Chicken pox Chickenpox
Measles Koplick spots (Measles)
Herpangina
  • Attendance at a kindergarten/child care center
  • Contact with herpangina cases
  • Residence in rural areas
  • Overcrowding
  • Poor hygiene
  • Low socioeconomic status
  • Skin
  • Oral Cavity
  • Characteristic enanthem- 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
Erythema, vesicles and ulcerating lesions in herpangina
Primary herpetic gingivoestomatitis[10]
  • 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
  • Clinical diagnosis
  • Confirmatory tests rarely needed
Localized candidiasis

Invasive candidasis

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

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.
  3. Moore, Zack S; Seward, Jane F; Lane, J Michael (2006). "Smallpox". The Lancet. 367 (9508): 425–435. doi:10.1016/S0140-6736(06)68143-9. ISSN 0140-6736.
  4. Ibrahim F, Khan T, Pujalte GG (2015). "Bacterial Skin Infections". Prim Care. 42 (4): 485–99. doi:10.1016/j.pop.2015.08.001. PMID 26612370.
  5. Ramoni S, Boneschi V, Cusini M (2016). "Syphilis as "the great imitator": a case of impetiginoid syphiloderm". Int J Dermatol. 55 (3): e162–3. doi:10.1111/ijd.13072. PMID 26566601.
  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.
  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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.


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