Rash with fever case file

Rash with fever case file

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 58

A 3-year-old boy is brought to the emergency department (ED) by his parents because of a rash that developed yesterday evening. The rash began on his neck and chest, then gradually spread to include his entire body except for his face. It does not seem to be painful nor pruritic. Although the child has had a fever and mild cough recently, he states that he “feels fine” and has not had any change in his behavior or oral intake. His parents deny any recent travel, camping or contact with animals. However, the boy does attend daycare, and several other children there have been ill recently. He is an otherwise healthy child with no history of major illness or medication allergies. He is taking acetaminophen as needed for the fever, and his immunizations are up to date.

On examination, his temperature is 38.9°C (102.1°F), blood pressure is 96/50 mm Hg, heart rate is 112 beats per minute, respiratory rate is 18 breaths per minute, and oxygen saturation is 98% on room air. The boy is sleeping comfortably in his mother arms but awakes easily during the examination. He does not appear acutely ill. His examination is unremarkable except for an erythematous maculopapular rash covering his neck, torso and extremities.

⯈ What is the most likely diagnosis?

⯈ How should this patient be managed?

ANSWER TO CASE 58:

Rash With Fever

Summary: This is a 3-year-old boy that presents with a rash, fever, and mild upper respiratory symptoms. On examination, he appears well and hydrated. He has a generalized maculopapular rash that spares the face.

• Most likely diagnosis: Viral exanthem
• Management: Symptomatic relief (eg, fever control) and follow up with his primary care physician as needed

ANALYSIS

Objectives

1. Define terminology used to describe rashes.
2. Review several causes of rash with fever.
3. Identify “red flags” associated with serious causes of rash.

Considerations

This 3-year-old boy has a maculopapular rash associated with fever and mild cough. The differential diagnosis is broad but can be focused by taking a detailed history and performing a thorough examination (that includes noting the appearance and distribution of skin lesions). Identifying specific etiologies may be difficult as multiple organisms and disease processes often cause similar types of rashes. Although most rashes are not associated with serious or life-threatening disorders, the ED physician must be able to identify those that are.

Approach To:

Rash With Fever

CLINICAL APPROACH

Patients presenting with rash and fever have a broad differential diagnosis that includes relatively minor as well as life-threatening etiologies. A thorough history and physical examination and familiarity with common patterns of skin lesions and their potential causes will help the emergency physician make a quick diagnosis and accurate treatment plan.

Important historical questions include initial appearance and location of skin lesions, direction and rate of progression, duration of rash, and associated features such as pain or pruritis. The clinician should also inquire about systemic complaints (eg, fever, cough, sore throat, vomiting, diarrhea, seizures, mental status changes, and joint pain) and recent exposures (eg, medications, known allergens, animals, chemicals, foods, travel, and sick contacts). Past medical, family, and sexual histories may also provide clues as to the etiology of the rash.

Patients with abnormal vital signs or evidence of toxicity may require initial stabilization before a detailed examination can be performed. If the patient is stable, care should be taken to inspect the entire body including mucous membranes. It is important to identify the color, morphology (listed in Table 58–1), location, and pattern of arrangement (including symmetry and configuration) of any lesions. A complete physical examination can help elicit additional diagnostic clues (eg, neck examination for nuchal rigidity and neurologic exam in patients with suspected meningococcemia [see Figure 58–1] or pelvic examination in those with possible disseminated gonococcemia). Although laboratory testing is not required for the evaluation of most rashes, it may be useful in some specific circumstances such

Figure 58–1. Fulminant meningococcemia with extensive purpuric patches.

as coagulation studies and platelet counts in patients with petechia or purpura or VDRL testing for suspected syphilis.

When developing a differential diagnosis, the clinician should consider three main categories: infectious, allergic, and rheumatologic. Table 58–2 includes

descriptions of several infectious causes of rash with fever. Differentiating an infectious from allergic rash can be difficult. Classically allergic rashes are pruritic rather than painful. They may be associated with the recent addition of a new medication or ingestion of an offending agent or appear in the area of contact with an environmental allergen. Wheals and urticaria are often associated with an allergic reaction. Rheumatologic rashes may appear similar to infectious or allergic ones but usually present with other systemic symptoms such as fever, fatigue, or arthralgias.

“Red flags” for potentially serious or life-threatening causes of rash include history of immunocompromised, fever, toxic appearance, hypotension, petechiae or purpura, diffuse erythema, severe or localized pain, and mucosal lesions. Petechiae and purpura can be associated with infectious conditions such as Rocky Mountain spotted fever or meningococcemia as well as coagulopathies such as disseminated intravascular coagulation. Diffuse erythema can be a harbinger of toxic shock syndrome, Staphylococcal scalded skin syndrome, or necrotizing fasciitis. Mucosal lesions may be a sign of Stevens-Johnson syndrome or toxic epidermal necrolysis (TEN). These conditions are classically associated with drug exposures (such as sulfa, phenytoin, and carbamazepine) or viral infections although many cases are idiopathic. Both conditions involve systemic symptoms (eg, fever), mucosal erosions, and diffuse cutaneous vesiculobullous lesions with epidermal detachment. They are differentiated by the amount of body surface area (BSA) involved (TEN: >30% BSA epidermal detachment). Patients with Stevens-Johnson syndrome and TEN are prone to infection and dehydration.

Treatment

Treatment is based on identification of the underlying process. The specific cause of many viral exanthems remains unidentified. These patients are usually treated symptomatically if they are otherwise well-appearing and hydrated. Rashes caused by bacteriologic organisms generally require antibiotic therapy. Table 58–2 lists some common disease processes with their appropriate diagnostic findings and treatments. Mild allergic reactions may be treated with removal of the offending allergen and antihistamines with or without corticosteroids. Patients with Steven-Johnson syndrome or TEN require admission for IV hydration and other supportive care.

COMPREHENSION QUESTIONS

58.1 A 6-year-old boy presents with a 3-day history of fever up to 102.2°F and rash. The mother reports associated cough, drainage from the right eye, and nasal irritation. What is the most likely diagnosis?

A. Rubeola

B. Roseola

C. Hand, foot, and mouth disease

D. Rubella

58.2 An 8-year-old boy presents with a pruritic rash and subjective fever after a weekend camping trip with the local Boy Scout troop. On examination, notice a linear, confluent maculopapular rash on the child leg. Which of the following findings is most specific for contact dermatitis secondary to an environmental exposure?

A. Fever

B. Maculopapular appearance

C. Pruritis

D. Linear confluence

58.3 A 2-year-old girl is brought to the ED by her parents for fever up to 103°F, decreased oral intake, and “not acting herself.” On examination, the child is lethargic. She has pain with flexion of her neck. Note small, nonblanching red dots on her legs and torso. What is the best management option?

A. PO challenge and reassess

B. Begin IV hydration and empiric antibiotic treatment

C. Fever control and discharge home

D. Obtain laboratory testing to narrow the differential diagnosis

58.4 A 4-year-old girl presents with a fever, desquamating bullous rash covering her torso, and ulcers in her mouth and vaginal area. Her parents want to know what caused her condition. Which is the best answer?

A. Viral infection

B. Medication use

C. Idiopathic

D. Any of the above

ANSWERS

58.1 A. The boy symptoms are consistent with rubeola (measles). He displays the classic rash and “three Cs” (cough, conjunctivitis, and coryza).

58.2 D. Fever, pruritis, and maculopapular rash can be seen with numerous conditions. However, the linear confluence is more consistent with an allergic reaction secondary to an environmental exposure (eg, pattern due to an object, such as poison ivy, brushing against the boy leg).

58.3 B. This girl is lethargic. She has fever, meningeal signs, and a rash concerning for meningococcemia. Empiric antibiotic therapy should be started immediately.

58.4 D. The girl presentation is worrisome for Stevens-Johnsons syndrome, which can be caused by any of the aforementioned etiologies.

CLINICAL PEARLS

⯈ A careful history and physical examination are useful in narrowing the differential diagnosis in patients with skin rashes.

⯈ Patients with rashes should be examined from head to toe, including mucous membranes.

⯈ “Red flags” for potentially serious or life-threatening causes of rash include history of immunocompromised, fever, toxic appearance, hypotension, petechiae or purpura, diffuse erythema, severe or localized pain, and mucosal lesions.

REFERENCES

Centers for Disease Control and Prevention. Diseases and Conditions. Available at: cdc.gov/ DiseasesConditions/Accessed: March 31, 2012. 

Cydulka RK, Garber B. Dermatologic Presentations. In: GL Mandell, JE Bennett, RD Douglas, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. Philadelphia, PA: Churchill Livingstone/Elsevier; 2010. 

Kliegman, R, Nelson WE. Nelson Textbook of Pediatrics. Philadelphia: Saunders; 2007. 

Letko E, Papaliodis DN, Papaliodis GN, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: A review of the literature. Ann Allergy Asthma Immunol. 2005;94(4):419-436. 

Marx JA, Hockberger RS, Walls RM, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia: Mosby/Elsevier; 2009. 

Schlossberg D. Fever and rash. Infect Dis Clin North Am. 1996;10:101-10. Tintinalli JE, Stapczynski JS. 

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill; 2011. 

Wolff K, Johnson RA, Fitzpatrick TB. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. New York: McGraw-Hill Medical; 2009.

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