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DIAGNOSTIC APPROACH
DIAGNOSTIC APPROACH


Characteristics of the rash  
Characteristics of the rash: Erythema multiforme, Erythema nodosum, Toxic epidermal necrolysis , Urticaria


Physical examination
Physical examination:


Laboratory testing
Vital signs
 
●General appearance to assess the severity of illness
 
●Strict attention to lymph nodes, mucous membranes, conjunctivae, and genitalia
 
●Meningeal signs and complete neurologic evaluation
 
●Liver and spleen size
 
●Joint examination
 
●Skin examination (t
 
Laboratory testing:  Appropriate laboratory testing includes [5]:
 
●Nonspecific tests such as complete blood count and urinalysis
 
●Blood cultures (including specific media and isolation methods for bacterial, mycobacterial, and fungal organisms) should be inoculated prior to beginning antimicrobial therapy
 
●Serologic tests, when appropriate (eg, for ''Coccidioides immitis'', hepatitis B, ''Toxoplasma gondii'', ''Borrelia burgdorferi'', ''Treponema pallidum'', dengue virus, and HIV)
 
●Antigen tests, when appropriate (eg, serum cryptococcal antigen)




Revision as of 20:07, 21 February 2021


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

Synonyms and keywords:
Fever :

Frenzy

Temperature

Feverishness

Heat

Ferment

Pyrexia

Excitement

Agitation

Febrile

Feverish

Furor

Sweat

Ecstasy

Febricity

Hyperthermia

Rush:

Reckless

Impetuous

Impulsive

Hasty

Overhasty

Foolhardy

Incautious

Precipitate

Precipitous

Premature

Careless

Heedless

Thoughtless

Fever and rash resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Fever with an accompanying rash is a common symptom constellation in patients presenting to clinicians' offices and emergency departments. Skin manifestations may provide the only early clue to an underlying infection, may be the hallmark of contagious disease, and/or may be an early sign of a life-threatening infection or serious noninfectious disorder. The differential diagnosis of fever and rash is extremely broad, but this symptom complex provides an opportunity for the diligent clinician to establish a probable etiology through a careful history and physical examination.

A systematic approach is crucial for establishing a timely diagnosis, determining early therapy when appropriate, and considering isolation of the patient if necessary.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes[20]

FIRE: Focused Initial Rapid Evaluation

The diagnostic approach to the child patient with fever and rash should focus on the appearance of the rash and the detailed epidemiologic history[37][38][39]

DIAGNOSTIC APPROACH

Characteristics of the rash: Erythema multiforme, Erythema nodosum, Toxic epidermal necrolysis , Urticaria

Physical examination:

Vital signs

●General appearance to assess the severity of illness

●Strict attention to lymph nodes, mucous membranes, conjunctivae, and genitalia

●Meningeal signs and complete neurologic evaluation

●Liver and spleen size

●Joint examination

●Skin examination (t

Laboratory testing: Appropriate laboratory testing includes [5]:

●Nonspecific tests such as complete blood count and urinalysis

●Blood cultures (including specific media and isolation methods for bacterial, mycobacterial, and fungal organisms) should be inoculated prior to beginning antimicrobial therapy

●Serologic tests, when appropriate (eg, for Coccidioides immitis, hepatitis B, Toxoplasma gondii, Borrelia burgdorferi, Treponema pallidum, dengue virus, and HIV)

●Antigen tests, when appropriate (eg, serum cryptococcal antigen)


Season[40][41]

Geography

Incubation period

Exposure history[42][43][44][45][46]

Arthropod exposures[47][48][49][50][51]

Medication history[52]

Immunization history[53][54][55][56]

Sexual history[57][58][59]

Immunocompetence of the host[60][61]

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References

  1. ↑ Ferguson LE, Hormann MD, Parks DK, Yetman RJ (2002). "Neisseria meningitidis: presentation, treatment, and prevention". J Pediatr Health Care. 16 (3): 119–24. PMID 12015670.
  2. ↑ Toews WH, Bass JW (1974). "Skin manifestations of meningococcal infection; an immediate indicator of prognosis". Am J Dis Child. 127 (2): 173–6. doi:10.1001/archpedi.1974.02110210023003. PMID 4204016 PMID 4204016 Check |pmid= value (help).
  3. ↑ Durack DT, Lukes AS, Bright DK (1994). "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 96 (3): 200–9. doi:10.1016/0002-9343(94)90143-0. PMID 8154507.
  4. ↑ Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ; et al. (2015). "Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association". Circulation. 132 (15): 1435–86. doi:10.1161/CIR.0000000000000296. PMID 26373316.
  5. ↑ Pant S, Patel NJ, Deshmukh A, Golwala H, Patel N, Badheka A; et al. (2015). "Trends in infective endocarditis incidence, microbiology, and valve replacement in the United States from 2000 to 2011". J Am Coll Cardiol. 65 (19): 2070–6. doi:10.1016/j.jacc.2015.03.518. PMID 25975469.
  6. ↑ Thorner AR, Walker DH, Petri WA (1998). "Rocky mountain spotted fever". Clin Infect Dis. 27 (6): 1353–9, quiz 1360. doi:10.1086/515037. PMID 9868640.
  7. ↑ Helmick CG, Bernard KW, D'Angelo LJ (1984). "Rocky Mountain spotted fever: clinical, laboratory, and epidemiological features of 262 cases". J Infect Dis. 150 (4): 480–8. doi:10.1093/infdis/150.4.480. PMID 6491365.
  8. ↑ Centers for Disease Control and Prevention (CDC) (2004). "Fatal cases of Rocky Mountain spotted fever in family clusters--three states, 2003". MMWR Morb Mortal Wkly Rep. 53 (19): 407–10. PMID 15152183.
  9. ↑ Kirk JL, Fine DP, Sexton DJ, Muchmore HG (1990). "Rocky Mountain spotted fever. A clinical review based on 48 confirmed cases, 1943-1986". Medicine (Baltimore). 69 (1): 35–45. PMID 2299975.
  10. ↑ Thorner AR, Walker DH, Petri WA (1998). "Rocky mountain spotted fever". Clin Infect Dis. 27 (6): 1353–9, quiz 1360. doi:10.1086/515037. PMID 9868640.
  11. ↑ Giuliano A, Lewis F, Hadley K, Blaisdell FW (1977). "Bacteriology of necrotizing fasciitis". Am J Surg. 134 (1): 52–7. doi:10.1016/0002-9610(77)90283-5. PMID 327844.
  12. ↑ Laucks SS (1994). "Fournier's gangrene". Surg Clin North Am. 74 (6): 1339–52. doi:10.1016/s0039-6109(16)46485-6. PMID 7985069.
  13. ↑ Todd J, Fishaut M, Kapral F, Welch T (1978). "Toxic-shock syndrome associated with phage-group-I Staphylococci". Lancet. 2 (8100): 1116–8. doi:10.1016/s0140-6736(78)92274-2. PMID 82681.
  14. ↑ Davis JP, Chesney PJ, Wand PJ, LaVenture M (1980). "Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention". N Engl J Med. 303 (25): 1429–35. doi:10.1056/NEJM198012183032501. PMID 7432401.
  15. ↑ Shands KN, Schmid GP, Dan BB, Blum D, Guidotti RJ, Hargrett NT; et al. (1980). "Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases". N Engl J Med. 303 (25): 1436–42. doi:10.1056/NEJM198012183032502. PMID 7432402.
  16. ↑ Stevens DL (1996). "The toxic shock syndromes". Infect Dis Clin North Am. 10 (4): 727–46. doi:10.1016/s0891-5520(05)70324-x. PMID 8958166.
  17. ↑ Rieder HL, Kelly GD, Bloch AB, Cauthen GM, Snider DE (1991). "Tuberculosis diagnosed at death in the United States". Chest. 100 (3): 678–81. doi:10.1378/chest.100.3.678. PMID 1889256.
  18. ↑ Dias MF, Bernardes Filho F, Quaresma MV, Nascimento LV, Nery JA, Azulay DR (2014). "Update on cutaneous tuberculosis". An Bras Dermatol. 89 (6): 925–38. doi:10.1590/abd1806-4841.20142998. PMC 4230662. PMID 25387498.
  19. ↑ Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM (2002). "Cutaneous tuberculosis: diagnosis and treatment". Am J Clin Dermatol. 3 (5): 319–28. doi:10.2165/00128071-200203050-00004. PMID 12069638.
  20. ↑ Cherry JD (1993). "Contemporary infectious exanthems". Clin Infect Dis. 16 (2): 199–205. doi:10.1093/clind/16.2.199. PMID 8443297.
  21. ↑ Griffin DE, Pan CH (2009). "Measles: old vaccines, new vaccines". Curr Top Microbiol Immunol. 330: 191–212. doi:10.1007/978-3-540-70617-5_10. PMID 19203111.
  22. ↑ Grose C (1981). "Variation on a theme by Fenner: the pathogenesis of chickenpox". Pediatrics. 68 (5): 735–7. PMID 6273782.
  23. ↑ Ozaki T, Ichikawa T, Matsui Y, Nagai T, Asano Y, Yamanishi K; et al. (1984). "Viremic phase in nonimmunocompromised children with varicella". J Pediatr. 104 (1): 85–7. doi:10.1016/s0022-3476(84)80596-x. PMID 6317835 PMID 6317835 Check |pmid= value (help).
  24. ↑ Nguyen QT, Sifer C, Schneider V, Allaume X, Servant A, Bernaudin F; et al. (1999). "Novel human erythrovirus associated with transient aplastic anemia". J Clin Microbiol. 37 (8): 2483–7. doi:10.1128/JCM.37.8.2483-2487.1999. PMC 85263. PMID 10405389.
  25. ↑ Servant A, Laperche S, Lallemand F, Marinho V, De Saint Maur G, Meritet JF; et al. (2002). "Genetic diversity within human erythroviruses: identification of three genotypes". J Virol. 76 (18): 9124–34. doi:10.1128/jvi.76.18.9124-9134.2002. PMC 136440. PMID 12186896.
  26. ↑ Servant A, Laperche S, Lallemand F, Marinho V, De Saint Maur G, Meritet JF; et al. (2002). "Genetic diversity within human erythroviruses: identification of three genotypes". J Virol. 76 (18): 9124–34. doi:10.1128/jvi.76.18.9124-9134.2002. PMC 136440. PMID 12186896.
  27. ↑ Suga S, Yoshikawa T, Nagai T, Asano Y (1997). "Clinical features and virological findings in children with primary human herpesvirus 7 infection". Pediatrics. 99 (3): E4. doi:10.1542/peds.99.3.e4. PMID 9099769.
  28. ↑ Suga S, Yoshikawa T, Nagai T, Asano Y (1997). "Clinical features and virological findings in children with primary human herpesvirus 7 infection". Pediatrics. 99 (3): E4. doi:10.1542/peds.99.3.e4. PMID 9099769.
  29. ↑ RAMMELKAMP CH, STOLZER BL (1961). "The latent period before the onset of acute rheumatic fever". Yale J Biol Med. 34: 386–98. PMC 2605065. PMID 14490142 PMID 14490142 Check |pmid= value (help).
  30. ↑ Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC; et al. (2004). "Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association". Circulation. 110 (17): 2747–71. doi:10.1161/01.CIR.0000145143.19711.78. PMID 15505111.
  31. ↑ Adler JL, Mostow SR, Mellin H, Janney JH, Joseph JM (1970). "Epidemiologic investigation of hand, foot, and mouth disease. Infection caused by coxsackievirus A 16 in Baltimore, June through September 1968". Am J Dis Child. 120 (4): 309–14. doi:10.1001/archpedi.1970.02100090083005. PMID 5493828 PMID 5493828 Check |pmid= value (help).
  32. ↑ Adler JL, Mostow SR, Mellin H, Janney JH, Joseph JM (1970). "Epidemiologic investigation of hand, foot, and mouth disease. Infection caused by coxsackievirus A 16 in Baltimore, June through September 1968". Am J Dis Child. 120 (4): 309–14. doi:10.1001/archpedi.1970.02100090083005. PMID 5493828 PMID 5493828 Check |pmid= value (help).
  33. ↑ Anagnostopoulos I, Hummel M, Kreschel C, Stein H (1995). "Morphology, immunophenotype, and distribution of latently and/or productively Epstein-Barr virus-infected cells in acute infectious mononucleosis: implications for the interindividual infection route of Epstein-Barr virus". Blood. 85 (3): 744–50. PMID 7530505.
  34. ↑ Peter J, Ray CG (1998). "Infectious mononucleosis". Pediatr Rev. 19 (8): 276–9. doi:10.1542/pir.19-8-276. PMID 9707718.
  35. ↑ Mackenzie A, Fuite LA, Chan FT, King J, Allen U, MacDonald N; et al. (1995). "Incidence and pathogenicity of Arcanobacterium haemolyticum during a 2-year study in Ottawa". Clin Infect Dis. 21 (1): 177–81. doi:10.1093/clinids/21.1.177. PMID 7578727.
  36. ↑ Meyer Sauteur PM, Theiler M, Buettcher M, Seiler M, Weibel L, Berger C (2020). "Frequency and Clinical Presentation of Mucocutaneous Disease Due to Mycoplasma pneumoniae Infection in Children With Community-Acquired Pneumonia". JAMA Dermatol. 156 (2): 144–150. doi:10.1001/jamadermatol.2019.3602. PMC 6990853 Check |pmc= value (help). PMID 31851288.
  37. ↑ O'Brien D, Tobin S, Brown GV, Torresi J (2001). "Fever in returned travelers: review of hospital admissions for a 3-year period". Clin Infect Dis. 33 (5): 603–9. doi:10.1086/322602. PMID 11486283.
  38. ↑ Lupi O, Tyring SK (2003). "Tropical dermatology: viral tropical diseases". J Am Acad Dermatol. 49 (6): 979–1000, quiz 1000-2. doi:10.1016/s0190-9622(03)02727-0. PMID 14639375.
  39. ↑ Suh KN, Kozarsky PE, Keystone JS (1999). "Evaluation of fever in the returned traveler". Med Clin North Am. 83 (4): 997–1017. PMID 10453260.
  40. ↑ Centers for Disease Control and Prevention (CDC) (2005). "Vibrio illnesses after Hurricane Katrina--multiple states, August-September 2005". MMWR Morb Mortal Wkly Rep. 54 (37): 928–31. PMID 16177685.
  41. ↑ Blake PA, Merson MH, Weaver RE, Hollis DG, Heublein PC (1979). "Disease caused by a marine Vibrio. Clinical characteristics and epidemiology". N Engl J Med. 300 (1): 1–5. doi:10.1056/NEJM197901043000101. PMID 758155.
  42. ↑ Craven RB, Barnes AM (1991). "Plague and tularemia". Infect Dis Clin North Am. 5 (1): 165–75. PMID 2051013.
  43. ↑ Fox JG, Lipman NS (1991). "Infections transmitted by large and small laboratory animals". Infect Dis Clin North Am. 5 (1): 131–63. PMID 2051012.
  44. ↑ Goldstein EJ (1991). "Household pets and human infections". Infect Dis Clin North Am. 5 (1): 117–30. PMID 2051011.
  45. ↑ Hankenson FC, Johnston NA, Weigler BJ, Di Giacomo RF (2003). "Zoonoses of occupational health importance in contemporary laboratory animal research". Comp Med. 53 (6): 579–601. PMID 14727806.
  46. ↑ Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ (1999). "Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group". N Engl J Med. 340 (2): 85–92. doi:10.1056/NEJM199901143400202. PMID 9887159.
  47. ↑ Fishbein DB, Dawson JE, Robinson LE (1994). "Human ehrlichiosis in the United States, 1985 to 1990". Ann Intern Med. 120 (9): 736–43. doi:10.7326/0003-4819-120-9-199405010-00003. PMID 8147546.
  48. ↑ Masters EJ, Grigery CN, Masters RW (2008). "STARI, or Masters disease: Lone Star tick-vectored Lyme-like illness". Infect Dis Clin North Am. 22 (2): 361–76, viii. doi:10.1016/j.idc.2007.12.010. PMID 18452807.
  49. ↑ Mackowiak PA, LeMaistre CF (1987). "Drug fever: a critical appraisal of conventional concepts. An analysis of 51 episodes in two Dallas hospitals and 97 episodes reported in the English literature". Ann Intern Med. 106 (5): 728–33. doi:10.7326/0003-4819-106-5-728. PMID 3565971.
  50. ↑ Bakken JS, Krueth J, Wilson-Nordskog C, Tilden RL, Asanovich K, Dumler JS (1996). "Clinical and laboratory characteristics of human granulocytic ehrlichiosis". JAMA. 275 (3): 199–205. PMID 8604172.
  51. ↑ Dumler JS (1997). "Is human granulocytic ehrlichiosis a new Lyme disease? Review and comparison of clinical, laboratory, epidemiological, and some biological features". Clin Infect Dis. 25 Suppl 1: S43–7. doi:10.1086/516164. PMID 9233663.
  52. ↑ Arndt KA, Jick H (1976). "Rates of cutaneous reactions to drugs. A report from the Boston Collaborative Drug Surveillance Program". JAMA. 235 (9): 918–23. PMID 128641.
  53. ↑ Weinberg A, Lazar AA, Zerbe GO, Hayward AR, Chan IS, Vessey R; et al. (2010). "Influence of age and nature of primary infection on varicella-zoster virus-specific cell-mediated immune responses". J Infect Dis. 201 (7): 1024–30. doi:10.1086/651199. PMC 3136368. PMID 20170376.
  54. ↑ Hayward AR, Herberger M (1987). "Lymphocyte responses to varicella zoster virus in the elderly". J Clin Immunol. 7 (2): 174–8. doi:10.1007/BF00916011. PMID 3033012.
  55. ↑ Arvin AM, Pollard RB, Rasmussen LE, Merigan TC (1980). "Cellular and humoral immunity in the pathogenesis of recurrent herpes viral infections in patients with lymphoma". J Clin Invest. 65 (4): 869–78. doi:10.1172/JCI109739. PMC 434474. PMID 6244336.
  56. ↑ Burke BL, Steele RW, Beard OW, Wood JS, Cain TD, Marmer DJ (1982). "Immune responses to varicella-zoster in the aged". Arch Intern Med. 142 (2): 291–3. PMID 6277260.
  57. ↑ Vanhems P, Allard R, Cooper DA, Perrin L, Vizzard J, Hirschel B; et al. (1997). "Acute human immunodeficiency virus type 1 disease as a mononucleosis-like illness: is the diagnosis too restrictive?". Clin Infect Dis. 24 (5): 965–70. doi:10.1093/clinids/24.5.965. PMID 9142802.
  58. ↑ de Jong MD, Hulsebosch HJ, Lange JM (1991). "Clinical, virological and immunological features of primary HIV-1 infection". Genitourin Med. 67 (5): 367–73. doi:10.1136/sti.67.5.367. PMC 1194734. PMID 1743707.
  59. ↑ Koss PG (1985). "Disseminated gonococcal infection. The tenosynovitis-dermatitis and suppurative arthritis syndromes". Cleve Clin Q. 52 (2): 161–73. doi:10.3949/ccjm.52.2.161. PMID 3928202 PMID 3928202 Check |pmid= value (help).
  60. ↑ Lopez FA, Sanders CV (2001). "Dermatologic infections in the immunocompromised (non-HIV) host". Infect Dis Clin North Am. 15 (2): 671–702, xi. doi:10.1016/s0891-5520(05)70164-1. PMID 11447714.
  61. ↑ Lopez FA, Sanders CV (2001). "Dermatologic infections in the immunocompromised (non-HIV) host". Infect Dis Clin North Am. 15 (2): 671–702, xi. doi:10.1016/s0891-5520(05)70164-1. PMID 11447714.
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