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.


Source

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

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