Rash Accompanied by Fever
Rash Accompanied by Fever: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Michael L. O’Dell
Fever with an accompanying rash represents a diagnostic challenge for even the most experienced of clinicians, as this combination of signs can represent trivial or life-threatening illnesses.
Approach
A useful way of approaching the differential diagnosis is to differentiate between the various entities that cause fever and illness by the types of rash they commonly cause. Various febrile diseases can present by more than one type of rash; however, this grouping allows the clinician to look at fewer causes rather than the entire spectrum of possible causes (1).
A. Petechial rashes (Chapter 15.3) are commonly associated with:
1. Treatable infections, including endocarditis, meningococcemia, gonococcemia, septicemia from any bacteria, and rickettsial infections, especially Rocky Mountain spotted fever (RMSF) (2).
2. Infectious causes not necessitating acute treatment, include enteroviruses, dengue fever, hepatitis B, rubella, and Epstein-Barr virus (EBV).
3. Noninfectious causes, including urticaria, include thrombocytopenia, scurvy, Henoch-Schönlein purpura, hypersensitivity vasculitis, acute rheumatic fever, and systemic lupus erythematosus (SLE).
B. Maculopapular rashes (Chapter 13.3) are commonly associated with:
1. Treatable infections, including typhoid, secondary syphilis, meningococcemia, gonococcemia, mycoplasmal infection, Lyme disease, psittacosis, rickettsial infections (especially RMSF).
2. Infectious causes not subject to acute treatment, including enterovirus, parvovirus B-19, human herpesvirus-6 (HHV-6), rubeola, rubella, adenovirus, Epstein–Barr virus (EBV), and primary human immunodeficiency virus-1 (HIV-1),
3. Noninfectious causes, including allergy, erythema multiforme (Chapter 13.2), SLE, dermatomyositis, serum sickness, and juvenile rheumatoid arthritis.
C. Vesiculobullous rashes (Chapter 13.8) are commonly associated with:
1. Treatable infections, including staphylococcal large vesicle impetigo and toxic shock syndrome, gonococcemia, rickettsial pox, varicella zoster, herpes simplex virus, Vibrio vulnificus sepsis, and folliculitis.
2. Infectious causes not requiring acute treatment, including enterovirus, parvovirus B-19, and HIV, although none of these three commonly present in this manner.
3. Noninfectious causes, including eczema vaccinatum and erythema multiforme bullosum.
D. Diffuse erythematous rashes are commonly associated with:
1. Treatable infections, including streptococcal scarlet fever, toxic shock syndrome, ehrlichosis (3), Streptococcus viridans (in chemotherapy patients), Corynebacterium haemolyticum pharyngitis, and Kawasaki’s disease.
2. Infectious causes requiring acute treatment, including enteroviral infections.
3. Noninfectious causes of erythema are only rarely associated with fever.
E. Urticaria rashes are commonly associated with:
1. Treatable infections, including mycoplasma infections and Lyme disease.
2. Infectious causes not requiring acute treatment, including enteroviral infections, adenoviral infections, EBV, HIV, and hepatitis.
3. Noninfectious causes of urticaria are only rarely associated with fever.
History
History is quite important and should include standard items, such as onset, duration, aggravating factors, relieving factors, and associated symptoms. Additionally, other factors to consider, include:
A. Exposure history. Are any other family members or close contacts ill? Is there a history of exposure to brackish water, mosquitoes, foreign travel, and so forth?
B. Are there any underlying illnesses or a significant possibility of immunologic compromise (e.g., undiagnosed HIV infection)?
Physical examination
A. Examine the lesions and their distribution carefully. Classify the rash as petechial, maculopapular, vesiculobullous, erythematous, or urticarial. Note the distribution of the rash. For instance, rubella and rubeola generally begin on the face and spread to the trunk, whereas RMSF petechiae tend to occur on the ankles and wrists first.
B. Conduct a general physical examination. Areas of particular concern are:
1. Head, eyes, ears, nose, and throat. The presence of Koplik’s spots is pathognomic for rubeola. The discovery of a tick lends support to the diagnosis of RMSF. Sinusitis may represent a source for meningococcemia. Pharyngitis in a young adult with diffuse erythema may be caused by C. haemolyticum. Mucous membrane swelling may indicate early anaphylaxis.
2. Lung examination. Expiratory wheezing, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis. Evidence of pneumonia is consistent with psittacosis and mycoplasma.
3. Cardiac examination. Cardiovascular collapse is associated with meningococcemia and other sepsis. A new murmur (Chapters 7.6 and 7.7) may indicate subacute bacterial endocarditis in a patient with subungual or scleral petechiae.
4. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea. A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.
5. Joint examination and extremities. A petechial rash near the ankles and wrists is suggestive of RMSF. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis and other rheumatologic conditions as well.
6. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.
Testing
should be directed by illnesses suspected, with life-threatening illnesses being tested for on reasonable suspicion. A complete blood count is generally useful, although life-threatening sepsis often presents without significant elevation of white blood count. In general, a blood culture should be obtained in all patients with petechial rashes and in those with signs of cardiovascular collapse.
Diagnostic assessment
Based on history and physical examination, the likelihood of various illnesses can be assessed. Patients who appear toxic should be treated as septic until initial laboratory and culture results can be evaluated (4).
References
1. Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996;10(1):101–110.
2. Drolet BA, Baselga E, Esterly NB. Painful, purpuric plaques in a child with fever. Arch Dermatol 1997;133(12):1500–1501.
3. Anonymous. Fever, nausea, and rash in a 37-year-old man [clinical conference]. Am J Med 1998;104(6):596–601.
4. Dellinger RP. Current therapy for sepsis. Infect Dis Clin North Am 1999;13(2):
495–509.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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