Rash with fever resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords:

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

Life-threatening causes of febrile rashes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Meningococcemia or Meningoencephalitis
• Thrombotic Thrombocytopenic Purpura (TTP)
• Disseminated Intravascular Coagulation (DIC)
• Bacterial sepsis(Pneumococcal, Staphylococcal)

Common Causes

Common causes of rash with fever are given below :

• Typhoid fever
• Dengue hemorrhagic fever
• Rocky Mountain spotted fever (RMSF)
• Scarlet fever
• Toxic Epidermal Necrolysis (TEN)
• Stevens-Johnson Syndrome (SJS)
• Henoch-Schonlein Purpura (HSP)
• Kawasaki disease
• Lyme disease
• Endocarditis
• Disseminated gonococcal infection
• Autoimmune vasculitis
  • Systemic lupus erythematosus (SLE)
  • Rheumatoid arthritis
  • Sjogren’s syndrome
• Varicella
• Necrotizing fasciitis
• Hand foot and mouth (HFM) disease
• Anaphylaxis
• Shingles
• Rubella
• Measles

Diagnosis

Shown below are 04 algorithms summarizing the diagnosis of Rash with fever in a patient:

Patient with Fever and Rash

Take complete history

Record Vital signs: ❑ Measure the temperature ❑Record Pulse rate ❑Record Blood pressure ❑Record Respiratory rate

Ask about associated symptoms: ❑ Vomiting ❑ Nausea ❑ Abdominal Pain ❑ Cough ❑ Sore throat ❑ Chest pain ❑Arthralgias

Ask about other medical history: ❑ Asplenia ❑ Infection or Inflammation ❑Sarcoid ❑ Malignancy ❑ Collagen vascular disease ❑Any recent medications ❑Valvular heart disease ❑Chronic liver disease ❑Solid organ or bone marrow transplantation ❑Steroid use ❑Chemotherapy related immune suppression

Ask about recent Exposure: ❑Communal living ❑ Tick exposure ❑ Dog exposure ❑ Salt water exposure ❑ Tampon use ❑ IVDU ❑Trauma and Diabetes Mellitus ❑Exposure to sexually transmitted disease, including risk factors for infection with human immunodeficiency virus (HIV)

Ask about recent travel history: ❑ International Travel history ❑Travel in the mid-Atlantic, central, western, and northeastern parts of the United States(Lyme disease is common) ❑Travel in wooded areas(Rocky Mountain spotted fever and tick-borne diseases are common) ❑ Recent camping fever (RMSF) and other tick-borne illnesses.

General Physical Examination: ❑General appearance-Is the patient toxic? or normal appearance ❑Look for new-onset heart murmur or nuchal rigidity ❑Nuchal rigidity. ❑Palpate Lymph nodes for Generalized lymphadenopathy ❑Conjunctival injection ❑Look for Nikolsky sign:Sloughing of full-thickness skin with lateral pressure ❑Look for any lesion on the back, buttocks, or perineum ❑ In diabetic patients check feet ❑Palpate abdomen for hepatosplenomegaly

Characterize rash

Maculopapular rash

Petechial/Purpuric rash

Vesiculobullous rash

Erythematous rash

Terminolgies used to diagnose Rashes

Term	Clinical Features
Lesion	Single,Small affected area
Rash	An eruption on the skin; more extensive than a single lesion
Macule	Well circumscribed area of change without elevation
Papule	Solid raised lesion ≤1 cm
Petechia	Small red/brown macule ≤1 cm that does not blanche
Purpura	Hemorrhagic area > 3 mm that does not blanch

If a patient present with fever with maculopapular rash then follow the algorithm given below:

Fever with maculopapular rash

Look at the rash and it's distribution

Central distribution with fever

Peripheral distribution with fever

❑Viral exanthem ❑Lyme disease ❑Still disease

Look for target lesion

Present

Absent

Stevens-Johnson Syndrome

Erythema Multiforme

Lyme disease

Characteristics: ❑ Usually occurs due to drug reaction ❑Diffusely distributed target lesions including the palms and soles ❑ Mucous membrane may be involved ❑Toxic appearing patient ❑Fever

Characteristics: ❑ Usually autoimmune ❑May follow Herpes simplex, Mycoplasma, Fungal diseases or may occur due to drug exposure (sulfa drugs, anticonvulsants, antibiotics) ❑ Mucous membrane not involved in EM minor ❑In EM major significant involvement of mucous membrane ❑Nonspecific upper respiratory tract infection, moderate fever, general discomfort, cough, sore throat, vomiting, chest pain, diarrhoea may occur before the onset of rash ❑Rash may be seen in the palms, soles,face, and extensor surfaces and eye involvement in 10%

Characteristics: ❑ Usually there is a history of travelling to wooden area ❑Tick-borne illness is caused by Borrelia burgdorferi ❑A big lesion with dark red border and central clearing known as Erythema migrans ❑Migratory arthalgia ❑Atrioventricular Nodal block ❑Myalgia ❑Fever ❑Bells palsy ❑Confusion ❑Meningitis

Meningococcemia

Rocky Mountain spotted fever

Syphillis

Characteristics: ❑ Infection with Neisseria meningitidis ❑ History of living in collge dormitory/millitary/prison ❑Erythematous and maculopapular that initially begins on wrists and ankles, then spreads and becomes petechial ❑Ill appearing patient ❑ Fever

Characteristics: ❑ Caused by Rickettsia rickettsii ❑ History of travel to wooden areas, primarily in the south-Atlantic region of the United States ❑Erythematous and maculopapular that initially begins on wrists and ankles, then spreads and becomes petechial ❑Ill appearing patient, can be in shock ❑High Fever

Characteristics: ❑ Caused by Treponema pallidum ❑Secondary syphilis may appear as rough, red, or reddish brown spots on the palms of the hands and the bottoms of the feet] ❑ Non-pruritic ❑Fever

If patient presents with Petechial/Purpuric rash

Fever with Petechial rash/Perpuric rash

Palpate the rash

Palpable

Non-palpable

Endocarditis

Henoch-Schonlein purpura

Disseminated gonococcal infection

Rocky Mountain spotted fever

Meningococcemia

Characteristics: ❑ History of IV drug use,Infective Endocarditis, Rheumatic fever, ❑ Mostly caused by Staphylococcus and Streptococcus ❑Look for Janeway lesions which are painless purple or brown erythematous macular lesions, usually affects the palms, soles, and fingers

Characteristics: ❑ Autoimmune systemic vasculitis that affects the legs, buttocks, and arms and kidneys. ❑Usually preceded by an infection or drug exposure. ❑ The classic triad comprises of purpura, abdominal pain, and arthritis in the knees, ankles, and elbows. ❑Pruritic ❑Nausea ❑Vomiting ❑Intussusception ❑Diarrhoea/Constipation

Characteristics: ❑ Caused by Neiserria Gonorrhoea ❑Rash maybe present in case of disseminated gonococcal infection. ❑ Affects the trunk, limbs, palms and soles, and usually spare the face, scalp and mouth.

Characteristics: ❑ Caused by Rickettsia rickettsii ❑ History of travel to wooden areas, primarily in the south-Atlantic region of the United States ❑Erythematous and maculopapular that initially begins on wrists and ankles, then spreads and becomes petechial ❑Ill appearing patient, can be in shock ❑High Fever

Characteristics: ❑ Infection with Neisseria meningitidis ❑ History of living in collge dormitory/millitary/prison ❑Erythematous and maculopapular that initially begins on wrists and ankles, then spreads and becomes petechial ❑Ill appearing patient ❑ Fever

DIC

TTP

Purpura fulminans

Characteristics: ❑Very ill patient ❑ ❑Complication of different serious and life-threatening diseases ❑Due to uncontrolled activation of clotting factors in the blood vessels, causing clotting of blood in the whole body ❑Bleeding in other tissues

Characteristics: ❑Purplish bruises or purpura/petechiae in the mouth ❑Yellowish color of the skin and sclera ❑Fatigue ❑Tachycardia ❑ Shortness of Breath

Characteristics: ❑Very ill patient ❑H/O previous infection most commonly by meningococcal or gram-negative organisms, pregnancy, massive trauma, end-stage malignant disease, hepatic failure, snakebites, transfusion reactions, and anything else that may precipitate DICs ❑Fever ❑ Shock ❑Rapid subcutaneous hemorrhage ❑Widespread organ involvement

If patient presents with Vesiculo-bullous Rash, follow the algoritm below:

Fever with Vesicobullous rash

Look at the rash and it's distribution

Diffuse distribution with fever

Localized distribution with fever

Varicella

Purpura fulminans

Disseminated gonococcal disease

DIC

Characteristics: ❑ It is caused by varicella-zoster virus (VZV) ❑Temperature up to 102°F ❑ Rash is generalized and pruritic,usually strats fromchest, back, and face, then spreads over the entire body ❑ Rash progresses rapidly from macular to papular to vesicular lesions before crusting ❑ Malaise

Characteristics: ❑Very ill patient ❑H/O previous infection most commonly by meningococcal or gram-negative organisms, pregnancy, massive trauma, end-stage malignant disease, hepatic failure, snakebites, transfusion reactions, and anything else that may precipitate DICs ❑Fever ❑ Shock ❑Rapid subcutaneous hemorrhage ❑Widespread organ involvement

Characteristics: ❑ Caused by Neiserria Gonorrhoea ❑Rash maybe present in case of disseminated gonococcal infection. ❑ Affects the trunk, limbs, palms and soles, and usually spare the face, scalp and mouth.

Characteristics: ❑Very ill patient ❑ ❑Complication of different serious and life-threatening diseases ❑Due to uncontrolled activation of clotting factors in the blood vessels, causing clotting of blood in the whole body ❑Bleeding in other tissues

Necrotizing fasciitis

Hand-foot-and-mouth disease

Characteristics: ❑ Very sick patient, may be in septic shock ❑Rapid spread of cellulitis with purpura/blistering, genitalia may be involved ❑Affercted area may have decreased sensation

Characteristics: ❑ Mainly seen in young children, caused by enterovirus ❑Symmetrical vesicles mainly hands, feet and mouth ❑Can extend to limbs and buttocks

Patient comes with Erythematous rash, follow the algorithm below:

Fever with Erythematous rash

Look for Nikolsky sign

Present

Absent

Staphylococcal Scalded Skin Syndrome:

Toxic Epidermal Necrolysis

Kawasaki disease

Scarlet fever

Toxic Shock Syndrome

Characteristics: ❑ Mainly seen in young children,usually less than 5 years of age. ❑Sudden onset of fever. ❑Erythema of the neck, axilla, and groin, and extreme skin tenderness ❑Mucous membrane not included ❑Shallow skin cleavage plane

Characteristics: ❑ Caused by drug reaction and most commonly associated with sulfa drugs. Other drugs include anticonvulsants, antivirals, NSAIDs, and allopurinol. ❑sudden-onset diffuse erythema with tender skin and sloughing ❑Rash starts from the face and around the eyes,then spread to whole body. ❑Massive skin sloughing in large sheets ❑ Patient is toxic ❑Myalgia ❑Mucous membrane is involved ❑Immunocompromised patients,HIV patients,patient with SLE,brain tumor are the high risk population

Characteristics: ❑ Mainly seen in young children,vasculitisdue to autoimmune or infective cause ❑Affects many systems, including the skin, mucous membranes, lymphatics, and blood vessels. ❑high fever for at least 5 days ❑Diffuse erythroderma ❑Strawberry tongue ❑Significant cervical lymphadenopathy ❑Conjunctival injection, peeling of the fingers and toes ❑Edema of the extremities

Characteristics: ❑ Strawberry tongue ❑ Tiny red macules or rough papules ❑Swollen then peeling hands ❑Evidence of streptococcal infection

Characteristics: ❑ Associated with tampon use in female,abscesses, nasal packing, surgical wounds, and postpartum conditions ❑Patient is toxic, in shock, and febrile ❑Diffuse erythematous rash that eventually leads to desquamation of the hands and feet.

Treatment

Shown below is an algorithm summarizing the treatment of rash with fever

If patient comes it maculopapular rash and fever:

Do's

• If patient started any new medication,immediately should stop taking it.
• If allergic to any known product/medication/food, stop taking it.

Don'ts

• Don’t use rubbing alcohol on skin
• Don't clean open wounds with hydrogen peroxide or bleach
• Don’t use a triple-antibiotic ointment

References

Fever with maculopapular rash

Stevens-Johnson Syndrome

Erythema Multiforme

Lyme disease

Meningococcemia

Rocky Mountain spotted fever

Lyme disease