Rash with fever resident survival guide

Rash with fever Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

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: Approach to febrile rash, Approach to Rash

Overview

A patient with fever may often come with rash.There are several causes for rash in febrile patients.Rash caused by infectious agents may have mild to severe outcome,so it is very important to diagnose the cause and treat accordingly.There can be some non-infectious causes as well.To diagnose efficiently a complete history must be taken which includes history of recent travel, contact with animals, medications, and exposure to forests and other natural environments. Additionally, time of onset of symptoms and morphology, location, distribution of the rash are be helpful in the clinical diagnosis.The most common causes are 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, Rubella, Measles.Usually,skin rashes are nonspecific and self-limited.If it is caused by viral infections unlike bacterial infections, they do not respond to antibiotics, so treatment usually focuses on relieving symptoms.If it is caused by bacterial infection specific antibiotic is prescribed.The treatment of non-infectious rashes depend on the underlying cause.

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:

Abbreviations: BP: Blood pressure, RR=Respiratory rate, HR=Heart Rate, HIV=Human immunodeficiency Virus, EM major=Erythema Multiforme Major, EM minor=Erythema Multiforme Minor, H/O=History of, DIC=disseminated intravascular coagulation, VZV=Varicella zoster virus,SLE=Systemic lupus erythematosus, TTP=Thrombotic Thrombocytopenic Purpura ,RMSF= Rocky Mountain spotted fever, IM=Intramuscular, IVIG= Intravenous Immunoglobulin, IVDU -Intravenous Drug User

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 ❑ Arthralgia

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 history

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 from chest, 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,vasculitis due 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:

Abbreviations: HIV=Human immunodeficiency Virus, EM major=Erythema Multiforme Major, EM minor=Erythema Multiforme Minor, H/O=History of, DIC=disseminated intravascular coagulation, VZV=Varicella zoster virus,SLE=Systemic lupus erythematosus, TTP=Thrombotic Thrombocytopenic Purpura ,RMSF= Rocky Mountain spotted fever, IM=Intramuscular, IVIG= Intravenous Immunoglobulin

Fever with maculopapular rash

Stevens-Johnson Syndrome

Erythema Multiforme

Lyme disease

Meningococcemia

Rocky Mountain spotted fever

Lyme disease

Treatment: ❑ Discontinuation of the offending agent ❑Optimizing fluid and electrolyte levels ❑ Admit to ICU

Treatment: ❑ Mild cases (EM minor) require only symptomatic support ❑Give analgesics, cold compresses, topical steroids ❑ Treatment of the specific cause if it is found and dermatological followup visit should be scheduled ❑In Erythema major more aggressive care is needed, start with discontinuation of the causative agent ❑Fluid and electrolyte balance, analgesics for pain ❑Clean the wounded area, Silver sulfadiazine should NOT be used ❑If oral lesions are present, soothing solution can be used ❑Steroid use may give rise to further complications than benefit ❑Dermatological and opthalmologic consultation (if eyes are involved).

Treatment: ❑ Doxycycline is the first-line treatment in nonpregnant adult patients ❑Amoxicillin can be used in children

Treatment: ❑ Ceftriaxone is first-line therapy. Vancomycin should be added ❑Rifampin is used as prophylaxis in close contacts of the patients,alternatively single-dose ciprofloxacin and IM ceftriaxone can be administered ❑ Dexamethasone can reduce neurologic sequelae if given early,even before administering antibiotics

Treatment: ❑ Doxycycline is the drug of choice in all nonpregnant patients and children. ❑ Pregnant patients can be treated with chloramphenicol

Treatment: ❑ Doxycycline is the first-line treatment in nonpregnant adult patients ❑ Children can be treated with amoxicillin.

If patient comes with Petechial/Purpuric rash

Fever with Petechial rash/Perpuric rash

Endocarditis

Henoch-Schonlein purpura

Disseminated gonococcal infection

Rocky Mountain spotted fever

Meningococcemia

DIC

Purpura fulminans

TTP

Treatment: ❑ Initial empiric therapy is Vancomycin or Ampicillin/Sulbactam plus an Aminoglycoside . ❑Rifampin is added in patients with prosthetic valves ❑Valve replacement should be considered in selected patients with infectious endocarditis. ❑Antimicrobial prophylaxis before certain dental and other procedures.

Treatment: ❑ Only supportive care, ❑Some patients need hospitalization for pain control, kidney biopsy, and/or administration of immunosuppressant agents or, occasionally, IVIG

Treatment: ❑ Patients with Disseminated gonococcal infection should be treated for at least 1 week with IV ceftriaxone. ❑ Treatment duration should be extended in patients who do not improve adequately

Treatment: ❑ Doxycycline is the drug of choice in all nonpregnant patients and children. ❑ Pregnant patients can be treated with chloramphenicol

Treatment: ❑❑ Ceftriaxone is first-line therapy. Vancomycin should be added ❑Rifampin is used as prophylaxis in close contacts of the patients,alternatively single-dose ciprofloxacin and IM ceftriaxone can be administered ❑ Dexamethasone can reduce neurologic sequelae if given early,even before administering antibiotics

Treatment: ❑ The primary treatment of DIC is treatment of the underlying condition ❑ In patients with DIC and bleeding or at high risk of bleeding and a platelet count of <50 x 10(9)/l transfusion of platelets should be considered but non-bleeding patients with DIC, prophylactic platelet transfusion is not given unless there is a high risk of bleeding. ❑Activated partial thromboplastin time (aPTT), administration of fresh frozen plasma (FFP) may be useful in DIC patients with prolonged prothrombin time (PT). ❑In patients where FFP can not be used due to chances of fluid overload,factor concentrates can be used. ❑ Patients with DIC with a primary hyperfibrinolytic state and severe bleeding can be treated with lysine analogues, such as tranexamic acid, 1 g every 8 hourly is administered.

Treatment: ❑ Admit to ICU immediately and hematology consultaion is needed ❑First-line therapy is treatment of the underlying cause ❑ Folate, vitamin K, fresh frozen plasma (FFP), cryoprecipitate, platelets, and red blood cell transfusions are given as needed; heparin can be used if there is any thrombi

Treatment: ❑ Immediate hematology/oncology consultation ❑Treatment of the underlying cause is done,Plasmapheresis, FFP are used. ❑ Platelets should not be given as it will precipitate additional thrombus formation

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

Fever with Vesicobullous rash

Necrotizing fasciitis

Hand-foot-and-mouth disease

Treatment: ❑Emergency surgical debridement of the affected tissues is the primary management ❑ Initial antibiotic treatment includes Ampicillin or ampicillin–sulbactam combined with metronidazole or clindamycin ❑Metronidazole, clindamycin, or carbapenems are used for anarobic coverage. ❑Ampicillin–sulbactam, piperacillin–tazobactam, ticarcillin–clavulanate acid, third or fourth generation cephalosporins, or carbapenems are used at a higher dosage if patient was recently admitted to hospital or were treated with antibiotics ❑Antibiotic should be continued for 4–6 weeks and up to 5 days after local signs and symptoms have resolved ❑Intravenous immunoglobulin (IVIG) can be used for neutralizing streptococcal toxins.

Treatment: ❑ Maintain hydration ❑Treat the fever,avoid Aspirin to prevent Reye's syndrome in children ❑Alleviate pain from mouth sores

Patient comes with Erythematous rash, follow the algorithm below:

Fever with Erythematous rash

Staphylococcal Scalded Skin Syndrome:

Toxic Epidermal Necrolysis

Kawasaki disease

Scarlet fever

Toxic Shock Syndrome

Treatment: ❑ Treatment includes antistaphylococcal antibiotics ❑ Fluid and electrolyte management, and local wound care

Treatment: ❑ Discontinuation of the offending agent ❑Fluid and electrolyte balance ❑Intravenous immune globulin (IVIG) may be helpful ❑ Sulfadiazine should not be used for wound care, as sulfa is the most common offending agent ❑Clean the wound and opthalmologic consultation if eyes are involved

Treatement: ❑ High dose aspirin ❑Hospitalization with supportive care, ❑IVIG

Treatment: ❑ IVIG, 2g/kg as a single IV infusion on diagnosis, within the first 10 days of the illness ❑ Aspirin is given 3-5mg/kg as a daily dose until normal echo on follow up(6 months).

Treatment: ❑Removal of the infective material ❑Administration of IV antibiotics, ❑Fluid resuscitation ❑IVIG Admit to ICU ❑

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