Rash with fever Approach
❖ I would like to shift pt to isolated room
❖ Vitals >if stable > cold approach
❖ I would like to take :
(A) Detailed hx :
1.Personal data : …..
2.Hx of presenting complain :
❖ Onset
❖ Duration
❖ Site & distribution (starting and spreading)
❖ Itching or not
❖ Painful or not
❖ Progression
❖ Recurrent
❖ Associated symptoms : fever ( ask about onset related to fever) , coryza symptoms , sore
throat , SOB , wheeze , …
❖ Preceding events: insect bite , contact with animal , food , drug
❖ Constitutional symptoms FWASL : Fever (if not mentioned) , Weight loss , loss of Appetite &
Activity , Sleep disturbance , LN enlargement
3.System involved : Musculoskeletal : Joint pain ,bone pain , …
4.Systemic Review :
❖ Cardio-pulmonary : chest pain , chest tightness , cough , SOB , ….
❖ GIT : abd pain , jaundice …
❖ CNS : (meningeal irritation)
❖ Urinary : hematuria
5.PMH :
❖ Similar condition
❖ Hosplitalization and blood transfusion
❖ Chronic illness : DM , HTN , HIV , autoimmune disease ..
❖ Drug Hx : current medication , Steroid use , allergies
6.Social Hx :
❖ Socio-economic status
❖ Hx of travelling /Hx of contact
❖ Sexual Hx
❖ IV drug user /Smoking
7.Vaccination Hx
(B) Examination :
1.General: general look (+LOC) , oral ex , lymph node ex , vitals including temp , capillary refill
2.Systemic: Cardiopulmonary (plural effusion) , GIT (organomegaly) ,CNS …
3.Skin:
❖ Generalized or localized (palms & soles involved or not )
❖ Type (maculopapular , vesicles…)
❖ Size and color (special appearance)
❖ Tender or not
❖ Blanching or not
(C) Inv :
❖ CBC , RBG ,UG , RFT+e , CRP , LFT , PFFM , blood/throat culture
❖ Others (PCR , serology , LP , bleeding profile )
DD of fever with Rash :
Viral Bacteria Others
Measles (Rubeola) Cellulitis Malaria
Rubella Scarlet fever Kawasaki disease
Dengue fever Typhoid fever Drug eruption
Infectious mononucleosis Meningococcal meningitis SSS
Acute HIV Secondary syphilis SJS/TEN
Varicella zoster (chicken box) Toxic shock syndrome
Disseminated HSV
Hand foot mouth syndrome
Red: maculopapular / Blue : vesicular rash
Spot diagnosis :
Measles Measles virus 3 C (cough , coryza , conjunctivitis ) + KopliK’s spot
Rash starts over the forehead and behind the ears, and
spreads within 24 h to the rest of the face, the trunk and the
limbs .
Rubella : Rubella virus The rash appears first on the face and spreads rapidly
downwards to the trunk and limbs , Forscheimmer spots (soft
palate)
Chickenpox VZV Central distribution ,lesions at different stages (macule
,papule ,vesicle, crust) , Vesicles are common in the mouth,
especially on the palate, and on other mucous membranes.
Kawasaki Medium arteries (1) Bilateral nonexudative conjunctivitis
disease vasculitis (2) Strawberry tongue and red, cracked lips
(3) Erythema of the hands and feet (peeling of figures)
(4) Maculopapular rash
(5) Cervical lymphadenopathy
Dengue fever Dengue virus Fluctuating fever with nausea, vomiting, headache, joint and
(Aedes mosquito) bone pain , severe backache , The rash fades as the fever
subsides .
Scarlet fever : Streptococcus Blanching sandpaper-like rash , cervical Lymphadenopathy ,
pyogenes pallor around the mouth is characteristic , membranous
tonsillitis , white coated tongue > strawberry tongue , peeling
of the skin
Typhoid fever Salmonella Chills , Rose spots , coated tongue , Relative bradycardia
typhi/paratyphi
Meningococcal N.meningiditis Headache , neck stiffness, vomiting , photophobia > coma
meningitis
(D) Mx :
Start with :
❖ Isolation (If not already isolated)
❖ Notification (to infection prevention & control Department) if notifiable disease
Measles Supportive ttt (O2 ,bed rest , paracetamol , encourage oral hydration )
+/- Vitamin A*
Rubella Supportive ttt
Ig / steroid if sever thrombocytopenia
Chicken pox Supportive
+/- Antiviral ttt (Acyclovire)*
Kawasaki Supportive
disease 2 g/kg of IVIG as a single Infusion
Aspirin should be administered until the patient is afebrile
Dengue fever Supportive
Close monitoring for at least 48 hrs (for warning sign of hemorrhagic shock &
dengue shock syndrome )
Scarlet fever After confirming diagnosis start antibiotics immediately :
Penicillin V or amoxicillin for 10 days
Supportive.
Typhoid fever Chloramphenicol OR Fluoroquinolone ( ofloxacin or ciprofloxacin)
supportive
Meningococcal Supportive ttt
meningitis Intravenous benzylpenicillin in high doses 300,000 units/kg/day
Ceftriaxone or cefotaxime are suitable alternatives.
Rifampicin for 2 days is recommended as prophylaxis for close
family contacts.
* Vit A dose : <6mo (50.000), 6 mo-11 mo (100.000 IU) , ≥12mo (200.000)
* Acyclovir dose (20 mg/kg/dose ,maximum: 800 mg/dose) given as 4 doses/day for 5 days
* Chloramphenicol 50mg/kg/day (2-3 wks ) OR Fluoroquinolone ( ofloxacin or ciprofloxacin)
15mg/kg/day (1wk)
References :Rooks Textbook of Dermatology , Nelson Textbook of Pediatrics KH.
