Fever and rash

Contagious potential
Rapid therapy
Diagnostic evaluation

Clinical setting

Severity of illness

Nature of rash





Emergent conditions presenting with fever and rash

Rapid recognition and therapeutic intervention are essential in certain diseases presenting with fever and rash to minimize as much as possible the associated morbidity and mortality. The major conditions involved include meningococcemia, Rocky Mountain spotted fever, staphylococcal toxic shock syndrome, streptococcal toxic shock-like syndrome, bacteremia or endocarditis with septic emboli, and the rapidly spreading cellulitis (Tables 17.2 and 17.3). All of these conditions can present with fever and rash in a fulminant, rapidly progressive form, requiring expedient therapeutic intervention, often on an empiric basis, before confirmation of the diagnosis, if the associated mortality rates are to be minimized.

Table 17.2 Approach to seriously ill patients with fever and rash

Clues Disease Diagnosis
Multiple purpuric lesions
Earliest lesions small of back
Rapid progression over hours
Meningococcemia Gram stain of pustules
Blood cultures
Tick exposure, headache, fever, rash 2nd–6th days
Wrists, ankles, progressing to palms, soles, trunk
Rocky Mountain spotted fever DFA of skin biopsy
Serology (CF)
Fever, rash, hypotension, menstruating female using tampons
Surgical wound or skin infection
Toxic shock syndrome Isolation of phage group I staphylococci
Fever, rash, hypotension, rapid onset of organ dysfunction Group A streptococcal toxic shock-like syndrome Evidence of group A streptococcal infection
Elderly or immunocompromised patient
Several lesions, macular to necrotic pustules
Bacteremia with septic emboli Gram stain of pustules
Blood cultures
Gram stain of buffy coat
Painful spreading lesions
Local trauma
Rapidly spreading cellulitis Clinical

Abbreviations: DFA = direct fluorescent antibody; CF = complement fixation.

Table 17.3 Characteristics of serious rashes

Onset with or after fever
Petechial lesions
Rapid spread
Purpuric lesions
Palmar/plantar involvement

Generally, the most serious and rapidly progressive of these are associated with a petechial rash. These 1- to 2-mm purple lesions do not blanch with pressure, often coalesce to form larger ecchymotic areas, and usually are in the presence of leukocytosis and thrombocytopenia. Meningococcemia, Rocky Mountain spotted fever, and bacteremia/endocarditis with septic emboli are perhaps the most notable. However, other causes include gonococcemia, typhus, and rat-bite fever; viral infection, including dengue, hepatitis B, rubella, and Epstein–Barr virus (EBV); and noninfectious causes, including thrombotic thrombocytopenia purpura, Henoch–Schönlein purpura, vasculitis, and scurvy.

Rapidly progressive diseases with erythematous rash include staphylococcal toxic shock syndrome and streptococcal toxic shock-like syndrome, as well as the rapidly progressive cellulitis, which often have a vesicobullous component. In these conditions, as well as with necrotizing fasciitis, the patient often looks toxic out of proportion to the extent of the rash.


Of all the diseases presenting with fever and rash, meningococcemia is the one most likely to be rapidly fatal without early recognition and treatment. The ominous palpable purpura in an acutely ill, febrile patient characteristically suggests this disease. Other features that may be helpful in earlier diagnosis include sore throat, fever, muscle tenderness, and headache in the presence of significant leukocytosis and thrombocytopenia. The illness tends to occur in late winter and early spring and is well known to occur under crowded living conditions. The initial rash may be maculopapular, with the earliest petechial lesions occurring over pressure points such as the small of the back, and can easily be overlooked. The rash can progress rapidly over a few hours to the more classic, petechial form with peripheral acrocyanosis. Management requires immediate recognition, vigorous fluid replacement, and rapid therapy with aqueous penicillin or a third-generation cephalosporin, 12 to 24 million units daily intravenously (IV). Patients presenting with signs of adrenal insufficiency also require steroid replacement. The use of gamma globulin is controversial for patients with meningitis. Dexamethasone for 2 days started just before or with the first dose of antibiotics is indicated.

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Jun 18, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Fever and rash

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