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  1. What are the most common causes of fever and rash in the hospitalized patient?

  2. What is the pathophysiology of fever and rash?

  3. What other clinical symptoms and findings are associated with fever and rash?

  4. How can laboratory tests help with diagnosis of the etiology of rash?

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Case 86-1

A 25-year-old graduate student who living in student housing presented to the hospital complaining of a 4-day history of upper respiratory tract symptoms that have progressed to include fever and rash on his extremities. The rash began on his hands and feet as a pink, flat rash, but has progressed over the last several hours to be purplish in nature, and extends now to his trunk and face. He is admitted to your service for further evaluation and treatment.

The rapid progression of the patient's rash and the appearance of macular rash that progressed to petechiae and purpura raised immediate concern for meningococcemia. The patient was placed in droplet precautions, blood cultures were collected, and ceftriaxone therapy initiated. Vital signs revealed blood pressure of 110/60, pulse 118, respiratory rate 24, and temperature of 39.2. No nuchal rigidity was noted. The patient's respiratory status declined and he was admitted to the ICU and intubated. Blood cultures grew Neisseria meningitidis at 24 hours and laboratory findings were consistent with DIC. A lumbar puncture was not performed due to severe thrombocytopenia. Multisystem organ failure developed rapidly. In addition to inotropic support, the use of recombinant activated protein C was considered.

The combination of fever and rash in the hospitalized patient has many different possible etiologies and the presentation can be varied, but an organized approach to the problem will alleviate some of the guesswork involved in diagnosing and treating these patients. This chapter will cover the presentation of rash plus fever and avoid a discussion of the causes of rash that are not typically associated with fever.

The clinical presentation of patients with rash and fever when they come to the hospital must be divided into categories of those who are critically ill vs. those who are not. Critically ill patients with rash often have fulminant onset of both the fever and the rash and must be diagnosed quickly to receive appropriate care. The timing of the rash is important for judging the severity of the disease with rapid onset often portending a more rapidly progressive course. The most worrisome cause of fulminant onset of rash is septicemia, especially purpura fulminans of meningococcemia, which can progress over hours or even minutes. More gradual or waxing and waning rash and fever suggest a more chronic process or one that may be noninfectious such as rheumatological disease or even a malignancy.

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Practice Point
  • Patients presenting in the hospital with rash and fever must be divided into two categories: those who are critically ill and those who ...

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