Febrile rash PDF

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Emergency Medicine Notes: Main features involved in Febrile rash....

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Febrile rash A rash can be defined as an acute, generalized rash that may be associated with fever or other constitutional symptoms. It can be a manifestation of an infectious disease, an autoimmune disease, or an adverse drug reaction. A thorough history and careful physical examination are essential to making a correct diagnosis. Although laboratory tests are helpful in confirming the diagnosis, test results are often not readily available. Exanthematic conditions can present without any seriousness ( roseola ), as they can be life threatening ( toxic shock syndrome ); therefore, the clinician must be prepared to diagnose these cases and decide on the patient's hospitalization, isolation, and empirical antibiotic therapy.

CLINICAL FINDINGS The history of patients with rash should include the following information:

1. Characterization of symptoms: ask about the duration and severity of fever, and the temporal relationship between fever and rash development. A rash that appears as soon as the fever subsides is typical of roseola infantum. In infectious erythema , “slapped cheeks” and a tracery-like rash can occur up to 1 week after the fever resolves. The story should also include the region where the rash started, the direction of spread, the speed with which it spread, and the presence or absence of itching. 2. History of vaccination: The patient vaccinated for rubella , measles and mumps (MMR) makes the diagnoses of rubella and measles less likely, but does not exclude them. The rash could be due to recent MMR vaccination. 3. Contact history: if there is recent exposure to sick patients and contact with sexually transmitted diseases. Ask about close contact with pregnant women, as rubella and parvovirus B19 (causer of infectious erythema) can harm the fetus. 4. Travel history: check the endemic diseases in the places where the patient has been. 5. Immune status: This is important because many illnesses that result in fever and rash present differently in immunocompromised patients. 6. Epidemiology for HIV: such as risky sexual behavior or injecting drug use. 7. Local epidemiology: check which infectious diseases are common in the local community and be informed about the occurrence of epidemics. 8. Use of medications: always ask about the drugs used in the last 30 days due to the need for differential diagnosis of exanthems of other etiologies with pharmacoderma. 9. Regarding the physical examination, the physician should evaluate the distribution, configuration and arrangement of the lesions. It is also important to assess vital signs and general status. Signs of toxemia, adenopathy, oral and conjunctival lesions, hepatosplenomegaly, alterations in pulmonary and cardiac auscultation, evidence of excoriation, soft tissue, osteoarticular and neurological system alterations should be investigated.

Table 1: Exanthema-related history and physical examination data History and physical examination data

Most frequently associated diseases

Exuberant constitutional symptoms, maculopapular rash, photophobia, conjunctivitis, cough, nasal congestion Koplik's spots

measles

Pink macules, mild constitutional symptoms, retroauricular and occipital adenomegaly, Forschheimer's spots ( Figure 2 )

rubella

Intense erythema on the cheeks, diffuse reticulated rash, arthritis in adults

infectious erythema

High fever without associated symptoms and rash when fever disappears

Sudden rash (roseola)

Maculopapular rash, generalized adenopathy, pharyngitis, eyelid edema, splenomegaly, Infectious Mononucleosis

rash with ampicillin Macular rash , frontal headache, retro-orbital pain, severe prostration, fever, myalgias,

Dengue

arthralgias Fever, arthralgia, myalgia, pharyngitis, generalized lymphadenopathy, maculopapular rash, oral ulcers associated with risky sexual behavior, transfusions or injecting drug use

acute HIV

Bright red, symmetrical, itchy macules and papules on the trunk and limbs associated with the use of medication

Pharmacodermy

Diffuse erythema, pharyngitis, perioral pallor, Pastia lines, raspberry tongue, peeling

Scarlet fever

Diffuse macular erythema, fever, hypotension, multisystem involvement, desquamation during convalescence

toxic shock syndrome

Scarlatiniform rash, but sometimes morbilliform or polymorphous erythema; cleft lips, raspberry tongue, edema of hands and feet with posterior desquamation; cervical Kawasaki disease

lymphadenopathy, pharyngitis, coronary artery vasculitis Transient salmon-colored maculopapular rash, located on the anterior trunk, that arises with fever. Associated hepatosplenomegaly, arthralgia, arthritis and lymph node enlargement

Still's disease

Fever, chills, headache, prostration, myalgia (mainly in the calves), conjunctival suffusion, trunk rash that may be composed of macules, papules, urticaria, or petechiae. Jaundice and shock in the icterohemorrhagic form

leptospirosis

Headache, nausea, vomiting, abdominal pain, diarrhea or constipation, splenomegaly, fever with relative bradycardia, pink macules that are located on the anterior trunk and add to digital pressure

Typhoid fever

Widespread hyperpigmented maculopapules affecting palms and soles; mucous plaques, flat condyloma lesions (mainly perianal), micropolyadenopathy, fever

secondary syphilis

DIFFERENTIAL DIAGNOSIS The differential diagnosis of febrile rash can be organized according to the characteristics of the rash. There is a special classification of exanthems that place them in two large groups: morbilliform exanthems and scarlatiniform exanthems ( Table 2 ). Morbilliform rashes consist of erythematous macules and papules, with areas of healthy skin between the lesions; they resemble the rashes seen in measles. Scarlatiniform exanthems consist of confluent erythema similar to scarlet fever. Rashes that do not fit the above classification, such as chickenpox (vesicular rash) and meningococcal disease (purpuric rash), will be studied in specific chapters.

Table 2: Classification of exanthems morbilliform rashes

scarlet-like rashes

The classic diseases that are part of this group are: measles, rubella, infectious erythema, roseola. Other diseases that can be mentioned in this group are: Dengue (in Dengue hemorrhagic fever, the rash can be petechial), acute HIV infection, enteroviruses, adenoviruses, Leptospirosis, Still's Disease, Typhoid Fever, Secondary Syphilis, Infectious Mononucleosis and other mononucleosis syndromes -like, such as toxoplasmosis, cytomegalovirus, acute viral hepatitis. Most eruptions

Scarlet fever, toxic shock syndrome, Kawasaki

caused by agents are morbilliform.

disease, pharmacoderma

Morbilliform Exanthemas Measles Measles starts with prodromal symptoms such as fever, myalgia, headache, nasal congestion, cough, conjunctivitis, and photophobia. In the prodromal phase, whitish spots also appear on the oral mucosa, the Koplik spots, which are pathognomonic of the disease. Measles rash starts around the 4th febrile day, with maculopapules that appear on the face and spread in a craniocaudal direction, with a tendency to confluence. Diagnosis is confirmed by serology.

Rubella Prodromal signs and symptoms of rubella are more common in adolescents and adults. In children, prodromes are rare, and infection is often subclinical (in up to 50% of cases). Signs and symptoms that precede the rash include: low-grade fever, headache, conjunctivitis, sore throat, cough, painful cervical, retroauricular, and occipital adenomegaly. Petechiae can be seen on the palate, called Forschheimer's spots. The rash has a short duration of 2nd3 days; it starts on the face, with craniocaudal progression and consists of pink macules that can converge. Arthralgias and arthritis are sometimes present, especially in women. Serology confirms the diagnosis.

Infectious Erythema Disease caused by parvovirus B19 is characterized by mild constitutional symptoms and two-stage rash. The initial stage appears as a bright, bright red erythema on the cheeks (“slapped cheeks”). The second stage of the exanthema is characterized by maculopapules that affect the trunk and limbs and form a diffuse lace, which disappears in6th 10 days but may recur for 3 weeks. Arthralgias or arthritis are common in adults, often simulating rheumatoid arthritis. In patients with chronic hemolytic anemias, there may be aplastic anemia. Infection in pregnant women can lead to hydrops fetalis. Diagnosis can be confirmed by serology.

Roseola Also called sudden rash, it is a disease caused by human herpesvirus type 6. It is more common in children and is rarely seen after 4 years of age. It is characterized by a rapid onset of high fever in a patient with good general condition, followed by the appearance of a rash when defervescence occurs. Serology can aid diagnosis.

Infectious Mononucleosis It is caused by the Epstein-Barr virus and is characterized by the triad of fever, pharyngitis, and generalized lymphadenopathy. Other common manifestations are malaise, headache, anorexia and myalgia. Periorbital edema, palatal petechiae, and hepatomegaly may also be seen. Splenomegaly is present in 50% of cases. Diffuse maculopapular rash (sometimes it may be urticarial or petechial) occurs in 10% of cases, however, when administered ampicillin or amoxicillin, the rash affects 90% of patients. Blood count shows atypical lymphocytosis and serology detects heterophile antibodies.

Dengue Symptoms of Dengue are fever, frontal headache, retro-orbital pain, myalgia, bone pain, arthralgia, nausea and prostration. A macular rash appears transiently on the 1st or 2nd day of illness. Painless cervical lymph node enlargement may appear in 50% of cases. Laboratory tests may reveal leukopenia with lymphocytosis and a slight increase in transaminases. Petechial rash, positive loop test, thrombocytopenia, hemoconcentration and bleeding indicate evolution to hemorrhagic dengue. Serological tests must be requested from the 5th day after the onset of fever.

Acute HIV Infection Acute HIV infection can be asymptomatic or develop symptoms from 1st6 weeks after contact, characterized by a flu-like illness or a monolike syndrome. The symptoms and changes in the physical examination presented are: fever, myalgias, arthralgias, headache, pharyngitis, generalized lymphadenopathy, maculopapular rash affecting mainly the trunk, palms and soles. In some cases, oral and/or genital ulcers are seen. Diagnosis at this stage can be made by searching for p24 antigen in blood or viral RNA in plasma.

Pharmacoderma Agent-related rashes vary widely, ranging from a benign macular rash to severe Stevens-Johnson syndrome. However, the most common medication-related rash is a macular rash that appears about 8 days after administration of the agent. This hypersensitivity reaction is typically symmetrical, starting in the upper portion of the torso or face and then progressing to the lower extremities. Itching, when present, helps to make the diagnosis. There may also be general symptoms such as fever, arthralgia and headache. Blood counts sometimes reveal eosinophilia. The Table 3 lists common causative agents of maculopapular rash.

Table 3: Agents that cause maculopapular rash. Allopurinol

Captopril

diclofenac

penicillins

Thiazides

Naproxen

Sulfonamides

Phenobarbital

Piroxicam

Phenytoin

Phenothiazines

dipyrone

Thiabendazole

nalidixic acid

Oral hypoglycemic agents

Scarlatiniform Exanthemas Scarlet fever Scarlet fever usually follows acute pharyngotonsillitis or a skin infection caused by group A beta-hemolytic streptococcus. 1st 10 years of age, rarely occurring in adults. The disease starts with fever, sore throat, chills, myalgia, nausea and headache. the rash arises from2nd3 days later, starting on the upper trunk and face, and characterized by diffuse erythema with tiny papules, leaving the skin with a sandpaper texture. Petechiae are also observed in the axillary, antecubital and inguinal folds (Pastia lines), perioral pallor, raspberry tongue, palate petechiae and exudative pharyngotonsillitis with painful submandibular lymphadenopathy. Rash involution is followed by diffuse desquamation, most prominent on the hands and feet. Laboratory tests reveal leukocytosis with a left shift and increased antistreptolysin O (ASLO).

Toxic Shock Syndrome It is a multisystemic febrile disease caused by toxin-producing strains of Staphylococcus aureus, which may be related to infection or just colonization of sites such as nasopharynx, bones, rectum and wounds. This syndrome is characterized by high fever, rash, hypotension, and involvement of 3 or more organs. Diffuse macular erythema, significant mucosal erythema (mainly conjunctival) and edema of the hands and feet occur. There may be ulceration of the oral, esophageal, vaginal and bladder mucosa. During the convalescence phase, palms and soles desquamate. Blood cultures are positive in5th to 15% of cases. Streptococcus can cause a similar condition, but it is associated with invasive disease, with severe pain in the affected site, greater positivity in blood cultures (50% or more) and higher mortality.

Kawasaki disease Kawasaki disease is a systemic vasculitis of unknown etiology, which mainly affects children under 5 years of age, and occasionally adults. It presents as a condition of high fever and scarlatiniform rash, but sometimes it is polymorphic. Also part of the clinical picture are pharyngeal hyperemia, cleft lip, raspberry tongue, conjunctivitis, edema of the hands and feet with subsequent desquamation, cervical adenopathy and, in 25% of cases, coronary artery vasculitis, sometimes with aneurysm formation. There is no specific confirmatory test for this disease. Diagnosis must be made based on clinical criteria.

COMPLEMENTARY EXAMS

laboratory tests Laboratory tests should be ordered according to clinical suspicion. Some general exams, such as blood count, biochemistry and blood cultures, often help in the differential diagnosis, in assessing the severity of the case and in managing it. Blood count may show leukopenia with lymphocytosis in viral exanthemas and, in the case of mononucleosis, large numbers of atypical lymphocytes, and sometimes thrombocytopenia. In scarlet fever and toxic shock syndrome, blood count findings are leukocytosis with neutrophilia. In Dengue hemorrhagic fever, significant thrombocytopenia and hemoconcentration are observed. Peripheral blood eosinophilia may reinforce the diagnostic hypothesis of Pharmacoderma. Liver enzymes can be elevated in Dengue, Infectious Mononucleosis, and Toxic Shock Syndrome. In the latter, urea and creatinine are often elevated. Blood cultures are essential in the assessment of septic conditions. When negative, they reinforce the diagnosis of staphylococcal toxic shock syndrome, since in streptococcal toxic shock the agent is identified in most cases. Serology seals the diagnosis of viral exanthems, however, it is often not readily available. In the case of Dengue, for example, it should only be collected from the 5th day of the onset of fever. Therefore, it is very important that the doctor knows how to make a clinical diagnosis.

Image Exams They should only be ordered if the clinical situation warrants it, such as a chest X-ray in a patient suspected of having pneumonia as a complication of measles. In the case of Kawasaki disease, imaging tests should be requested to assess the involvement of the coronary arteries, such as echocardiography, magnetic resonance angiography or conventional angiography.

TREATMENT The treatment of different types of rash is often supportive, as with most viral rashes. The Table 4 summarizes the treatment of certain selected cases.

Table 4: Treatment of selected causes of febrile rash Causes

Treatment Rest, maintenance of hydration. A single dose of vitamin A is recommended in populations deficient in this vitamin and in individuals at risk of severe involvement (eg, patients with immunodeficiency, malnutrition, evidence of xerophthalmia, or problems with intestinal absorption). The dose is 200,000 IU in capsule or

measles

aerosol.

rubella, infectious erythema,

Symptomatic treatment. In Infectious Mononucleosis, corticosteroid therapy can be useful in cases of

roseola,

complications with airway obstruction due to tonsillar hypertrophy, severe thrombocytopenia and hemolytic

infectious

mononucleosis

anemia.

Dengue

Symptomatic. Avoid AAS. In case of hemorrhagic dengue, hospitalization and parenteral hydration. The current recommendation of the Ministry of Health is not to indicate antiretroviral therapy at this stage

Acute HIV Infection

of the infection.

Penicillin G benzathine 1,200,000 U via IM single dose. Patients allergic to penicillin: erythromycin 500 mg Scarlet fever

orally every 6 hours, or clindamycin 300 mg orally every 8 hours for 10 days. Hospitalization, fluid resuscitation. Staphylococcal Toxic Shock Syndrome: Oxacillin 2 g EV every 4 or 6 hours, for 10 to 15 days. streptococcal toxic shock syndrome: penicillin G 3rd 4 million IV units every 4 hours, associated with clindamycin 600 to 900 mg IV every 8 hours per 10 to14 days. Apply mupirocin ointment to infected areas and perform abscess drainage or debridement when necessary.

toxic shock syndrome

In both types of shock, consider IV immunoglobulin in cases that do not improve despite adequate therapy. Aspirin in the dose of 30 to100 mg/kg/day and IV immunoglobulin in a single dose of 2 g/kg in 10 hours. The aspirin dose should be reduced to3rd 5 mg/kg/day after defervescence, which usually occurs around the

Kawasaki disease

14th day of illness. High dose aspirin (1 g VO 3 times/day) or other NSAIDs. Half of the patients require prednisone,

Still's disease

sometimes in doses greater than 60 mg/day by mouth, or TNF inhibitors.

leptospirosis

doxycillin 100 mg VO 2 times/day for 7 days can be administered early.

Penicillin 1.5 to3.5 million units every 6 hours IV or ceftriaxone 1 g/day IV. In mild to moderate cases,

Fluoroquinolones are the treatment of choice. Ciprofloxacin 750 mg twice daily or levofloxacin 500 mg once daily5th to 7 days in uncomplicated cases and 10 to14 days to severe infection. Ceftriaxone 2 g/day Typhoid fever

IV for 7 days is also effective.

secondary syphilis

Penicillin G benzathine 2 doses of 2,400,000 U IM applied 1 week apart.

IMPORTANT TOPICS febrile rash is a common finding in clinical practice and may be a manifestation of a mild disease or a disease with high mortality; the physician needs to know how to make the clinical diagnosis, as the serologic result is often late. In the clinical history, one should ask about the onset and progression of the rash; try to characterize the symptoms, remembering the most characteristic of each disease, such as photophobia, conjunctivitis and measles cough; retro-orbital pain in Dengue; important pruritus in pharmacoderma. Check vaccination history, research contact history, travel, immune status, HIV epidemiology and use of medications. The patient's age range is also very important, as diseases such as measles, infectious erythema, sudden rash, scarlet fever and Kawasaki disease are more prevalent in children than in adults. Physical examination should be ...