A generalized eruption manifested by macules and papules1. 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
- 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
- appears 2 - 6 months after primary infection
- may also see condylomata lata: soft, flat-topped, moist, red-to-pale papules, nodules or plaques
- 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
- gonococcus disseminates from infected mucosal site and a affects skin and joints
- erythematous macules evolve into hemorrhagic pustules, acral (peripheral) body parts more affected
- 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)
- 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
- 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
- most commonly seen with allogeneic bone marrow transplantation. Less often with autologous bone marrow transplantation or blood transfusion
- 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