18 y/o ill-appearing male presents with this rash. Other than supportive care, what four additional treatments should be considered?

A generalized eruption manifested by macules and papules

1. doxycycline: Rocky Mountain Spotted Fever

  • incidence highest 5 - 9 y/o
  • transmitted by tick, although only 60% have knowledge of recent tick bite
  • organisms attach to vascular endothelial cells causing generalized vasculitis
  • occurs only in western hemisphere; in US highest incidence in Oklahoma, North Carolina, Virginia, Maryland, Georgia, Michigan, Alaska, Montana, South Dakota
  • fever, severe headache, myalgias
  • early lesions are blanchable macules which then evolve into deep red non-blanchable, papules; rash characteristically spreads centripetally
2. doxycycline: Ehrlichiosis

  • tick borne illness
  • while Ehrlichiosis is often known as Rocky Mountain Spotted fever without the rash, this is only partially true, as a small minority of patients will have a macularpapular exanthem
  • for more information regarding ehrlichiosis, see previous posts, here and here
3. penicillin G benzathine (or doxycycline): Secondary Syphilis

  • appears 2 - 6 months after primary infection
  • may also see condylomata lata: soft, flat-topped, moist, red-to-pale papules, nodules or plaques
4. ceftriaxone: Meningococcemia

  • incidence highest 6 months - 3 years
  • 50 - 80% with meningococcemia develop meningitis
  • early lesions are sparsely distributed macules/papules which then evolve into petechiae/purpura
5. ceftriaxone: Disseminated Gonococcal Infection

  • gonococcus disseminates from infected mucosal site and a affects skin and joints
  • erythematous macules evolve into hemorrhagic pustules, acral (peripheral) body parts more affected
6. ceftriaxone: Typhoid fever

  • febrile illness with non-specific abdominal pain and rash 5 - 21 days after ingestion of salmonella in contaminated food or water, often after foreign travel
  • rash is faint salmon colored macules on trunk and abdomen (rose spots)
7. penicillin G benzathine (or ceftriaxone): Scarlet Fever

  • site of group A strep infection: pharynx, infected surgical or other wound
  • rash appears 1 - 3 days after onset of infection
  • begins with finely punctate erythema on the upper truck which becomes confluently erythematous. Rash is accentuated in skin folds (Pastia's lines). Exanthem fades within 4 - 5 days and is followed by desquamation
8. steroids: Drug Hypersensitivity Syndrome

  • most commonly a reaction to antiepileptic drugs and sulfonamides
  • onset generally 2 - 6 weeks after initiation of drug
  • eosinophilia or presense of atypical lymphocytes
  • potential systemic involvement: lymphadenopathy, interstitial nephritis, interstitial pneumonititis, carditis
9. steroids: Graft-Verus-Host Disease

  • most commonly seen with allogeneic bone marrow transplantation. Less often with autologous bone marrow transplantation or blood transfusion
10. amphotericin B: systemic fungal infection with dissemination to skin

  • consider in immunocompromised host

Bottom Line: In a sick patient with maculo-papular rash, consider empiric treatment with doxycycline, ceftriaxone, steroids and/or amphotericin B to cover the above disease entities in addition to standard supportive measures which should cover erythema infectiosum (parvovirus B19), cytomegalovirus, epstein-barr virus, herpes virus type 6, measles, german measles, echovirus, coxsackie, adenovirus.


Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed.

Image source: http://www.aafp.org/afp/20050615/2323_f1.jpg
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