2. Aim of the presentation
• Outlining an approach towards a patient presenting with fever and
rash
• Differentiating between various presentation of rashes
• Basic lab investigations
• Approach towards Management
4. Patient Particulars
45 Yr old male,serving soldier
Resident of Kollam,Kerala
Posted at J&K,on annual leave for 28 days at Kollam
Presenting Complaints
Fever
08 days
Joint pain
Rash 2 days
.
5. H/O PI
Fever
Moderate to high grade
Continous
A/w with chills / rigors
No evening rise
No night sweats
Joint pain
Continuous
Severe
Started with fever
Involving large joints
8. No history of
•Sore throat
•Pain abdomen
•Nausea/vomiting
•Loose stools
•Yellowish disclouration of sclera
•Burning micturition
•Drug/Alcohol intake
•Recent vaccination
•Weight loss
9. PAST HISTORY
No similar history in the past
No h/o TB / DM /HTN/ blood transfusion/IV Drug usage
PERSONAL HISTORY
Non alcoholic,non-smoker
Bowel and bladder habits normal
No h/o high risk sexual behaviour
10. TRAVEL HISTORY
H/o travel from J&K ,where he was posted,to
his hometown back in Kerala
DRUG HISTORY
No history of any drug intake
FAMILY HISTORY
Nil relevant
11. General Examination
• Average built and nourished
• Height-160 cms Weight-58 kgs
• BMI-22.6 kg/m²
• Temp-101 F(at admission)
• Pulse-84/min, regular
• BP-126/80 mm Hg right arm supine
• Resp rate-22/min regular
• CRT-2 secs
• No pallor/icterus/cyanosis/clubbing/lymphadenopathy
12. Multiple maculopapular rashes over
-trunk
-legs
-palate
Non-blanching,
erythematous,
non-pruritic,
no hypo/hyper pigmentation
21. Investigations-Later in the day
At 2030 hrs
Platelets 16000/ml
TLC 5200/ml
ESR 12 mm fall in first hour
NS1 antigen positive
IgM/IgG for dengue Positive/negative
ICT/PBS for MP negative
Widal test negative
Aim-To look for a definitive cause of
thrombocytopenia
22. What was done??
• INITIAL MANAGEMENT IN ICU –Aiming at
resuscitation
• Managed as a case of Dengue haemorrhagic fever
• 4 RDP CONCENTRATE TRANSFUSED**
• IV FLUIDS - 2 Ringer’s Lactate*** + 1 NS
• 1 NS WITH 1 AMPULE MVT IV INFUSION
• TAB PCM 500 MG SOS
***http://www.nejm.org/doi/full/10.1056/NEJMoa044057a double-blind, randomized
comparison of Ringer's lactate, 6 percent dextran 70 & 6 percent hydroxyethyl starch for initial
resuscitation in dengue shock syndrome recommends Ringer’s Lactate as fluid of choice
23. High risk patient
-Platelet count <20,000/cumm
-Prophylactic platelet transfusion.
Moderate risk
-Platelet count -21-40,000/cumm
-Transfused with platelet only if they have any hemorrhagic symptoms.
Low risk
-Platelet count >40,000/cumm but <100,000/cumm
-Observed and monitored carefully ,transfusion only if haemorrhagic symptoms seen
No risk category
-Platelet count >100,000/cumm.
-Never be transfused with platelet
-Should be managed on IV fluids and supportive therapy.
**Guidelines regarding platelet transfusion in DHF patients
**Source::IJTM-Indian Journal of Transfusion
Medicine
24. Investigations-Day 2
DAY 1 DAY 2
Hb 12.5 gm % 14.8 gm%
PCV 40% --
TLC 5400/ml 7000/ml
DLC N41L50E03M09 N18L72E01M09
Platelets 20,000/ml 23,000/ml
Coagulation
profile
NAD --
25. AT ICU
• 1 NS WITH 1 AMPULE MVT IV INFUSION
• TAB PCM 500 MG SOS
26. Investigations-Day 3
DAY 1 DAY 2 DAY 3
Hb 12.5 gm % 14.8 gm% 14.7 gm%
PCV 40% -- --
TLC 5400/ml 7000/ml 7800/ml
DLC N41L50E03M09 N18L72E01M09 N33L60E02M05
Platelets 20,000/ml 23,000/ml 72000/ml
Coagulation
profile
NAD -- --
Aim-monitoring progress/detect any worsening due to
complications
27. Patient shifted to Medical Ward
• TAB MVT 1 OD
• TAB RANITIDINE 150 MG BD
28. DAY 1 DAY 2 DAY 3 DAY 4 DAY 5
Hb 12.5 gm % 14.8 gm% 14.7 gm% 15.2 gm % 15.1 gm%
PCV 40% -- -- -- --
TLC 5400/ml 7000/ml 7800/ml 8400/ml 8300/ml
DLC N41L50E03M0
9
N18L72E01M0
9
N33L60E02M
05
N34L59E02M
05
N34L59E02M
05
Platelets 20,000/ml 23,000/ml 72000/ml 1,00,000/ml 1,00,400/ml
Coagulatio
n profile
NAD -- -- -- --
Investigations-DAY 4 & 5
Aim-monitoring of recovery
29. Patient recovered well and was discharged on the 10th
day
Platelet count at discharge=1,70,000/ml
Final Diagnosis:: Dengue Haemorrhagic Fever
FURTHER COURSE
31. Approaching a c/o Fever with rash
• RASH AND FEVER -The condition can be a primary skin disorder or a
symptom of a systemic process
• Hence,a detailed history can be quite helpful in identifying the cause of fever
and a rash.
Specific history of
• Recent travel.
• Animal exposure
• Insect bites.
• Drug ingestion
• Contact with ill persons
• Immune status
• The time of year
• Any rash that is sudden in onset and covers a large part of the body
• The timing of rash in relation to fever
32. Special emphasis on the following
• Conditions associated with valvular heart disease.
• Sexually transmitted diseases.
• Immunosupression from chemotherapy.
• Immune status is particularly important because many of
the diseases that result in fever and a rash present
differently in immunocompromised patients.
• Details of rash-site,direction of spread,relation with
fever,h/o application of oral/topical medication
33. • D/Ds for adult patient with fever and rash are extensive
• Classified according to the morphology
– Maculopapular, centrally and peripherally distributed
– Desquamative
-- Vesiculobullous/ pustular
– Nodular
– Purpuric
• Potential causes include viruses, bacteria, spirochetes,
rickettsiae and drugs
40. Fever with Maculopapular Eruptions
CENTRAL
ERUPTIONS
PERIPHERAL
ERUPTIONS
Rubeola Erythema Multiforme
Rubella Secondary Syphilis
Roseola Meningococcemia
Other Viral infections*
Erythema infectiosum
Dengue fever
Penicillin-induced rash
41. "Really Sick Champions Must Try Duck Eggs!”
• Appearance of rash in a febrile patient
– 1st day: Rubella
– 2nd day: Scarlet fever/ Smallpox
– 3rd day: Chickenpox (1- 5 days)
– 4th day: Measles (Koplik spots seen a day prior to the rash)
– 5th day: Typhus & rickettsia (this is variable)
– 6th day: Dengue (trunk;dorsum of hands &feet)
– 7th day: Enteric fever (Rose spots over abdomen, flanks, back)
42. Take home messages
• Fever with rash may represent a life-threatening condition
• Chronology of rash appearance / associated symptoms may give clue
to underlining disease
• Essential to enumerate past history/ drug intake / immune status
• Differentiating between benign rash from rash presenting as
manifestation of systemic disease is important
• Prompt decisions regarding hospitalization, isolation should be taken
even before investigation results are available.
43. REFERENCES
• 1)Harrison’s textbook of medicine 17th
edition
• 2)emedicine.medscape.com
• 3)The Indian Journal of Transfusion medicine
• 4)www.cochranelibrary.com
• 5)www.Nejm.org
Macule-Circumscribed area of change in normal skin color, with no skin elevation or depression; may be any size
Papule-Solid, raised lesion up to 0.5 cm in greatest diameter
Nodule-Similar to papule but located deeper in the dermis or subcutaneous tissue; differentiated from papule by palpability and depth, rather than size
Plaque-Elevation of skin occupying a relatively large area in relation to height; often formed by confluence of papules
Vesicle-Circumscribed, elevated, fluid-containing lesion less than 0.5 cm in greatest diameter; may be intraepidermal or subepidermal in origin
Bulla-Same as vesicle, except lesion is more than 0.5 cm in greatest diameter
