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

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

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

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