Rash with fever resident survival guide

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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

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.[1]

Common Causes

Common causes of rash with fever are given below :[1]

Diagnosis

Shown below are 04 algorithms summarizing the diagnosis of Rash with fever in a patient:[2][1]


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
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 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[1]


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:[2]



 
 
 
 
 
 
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:[2]

 
 
 
 
 
 
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:[3]



❑ 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:[4]

❑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:[2]

 
 
 
 
 
 
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:[5]

❑ 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:[2]

 
 
 
 
 
 
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[2][6][7][8][9]

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:[7]

❑ 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:[6]

❑ 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:[8]

❑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:[9]

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

References

  1. 1.0 1.1 1.2 1.3 Kang JH (September 2015). "Febrile Illness with Skin Rashes". Infect Chemother. 47 (3): 155–66. doi:10.3947/ic.2015.47.3.155. PMC 4607768. PMID 26483989.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Murphy-Lavoie, Heather; LeGros, Tracy (2018). "The Algorithmic Approach to the Unidentified Rash": 1–5. doi:10.1007/978-3-319-75623-3_1.
  3. Gomes, Rafael Tomaz; Tiberto, Larissa Rezende; Bello, Viviane Nardin Monte; Lima, Margarete Aparecida Jacometo; Nai, Gisele Alborghetti; Abreu, Marilda Aparecida Milanez Morgado de (2016). "Dermatologic manifestations of infective endocarditis". Anais Brasileiros de Dermatologia. 91 (5 suppl 1): 92–94. doi:10.1590/abd1806-4841.20164718. ISSN 0365-0596.
  4. "Thrombotic Thrombocytopenic Purpura | NHLBI, NIH".
  5. "Chickenpox | For Healthcare Professionals | Varicella | CDC".
  6. 6.0 6.1 Levi M, Toh CH, Thachil J, Watson HG (April 2009). "Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology". Br. J. Haematol. 145 (1): 24–33. doi:10.1111/j.1365-2141.2009.07600.x. PMID 19222477.
  7. 7.0 7.1 Lohani S, Nazir S, Tachamo N, Patel N (2016). "Disseminated gonococcal infection: an unusual presentation". J Community Hosp Intern Med Perspect. 6 (3): 31841. doi:10.3402/jchimp.v6.31841. PMC 4942509. PMID 27406461.
  8. 8.0 8.1 Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A (2014). "Current concepts in the management of necrotizing fasciitis". Front Surg. 1: 36. doi:10.3389/fsurg.2014.00036. PMC 4286984. PMID 25593960.
  9. 9.0 9.1 "Clinical Practice Guidelines : Kawasaki disease".