Infectious Diseases in Critical Care Medicine

2

Fever and Rash in Critical Care

Lee S. Engel, Charles V. Sanders, and Fred A. Lopez

Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A.

INTRODUCTION
There are numerous potential etiologic agents that can cause the syndrome of fever and rash.
Skin manifestations may be an early sign of a life-threatening infection. The ability to rapidly
identify the cause of fever and rash in critically ill patients is essential for the proper
management of the patient and protection of the health care worker(s) providing care for that
patient.
A rapid method to narrow the potential life-threatening causes of fever and rash has been
described by Cunha (1). Patients from the community who are ill enough to be admitted to the
critical care unit with the syndrome of fever and rash from outside the hospital will most likely
have meningococcemia, Rocky Mountain spotted fever (RMSF), community-acquired toxic
shock syndrome (TSS), severe drug reactions, severe bacteremia,Vibrio vulnificussepticemia,
gas gangrene, arboviral hemorrhagic fevers, dengue infection, or measles (Table 1). Patients
who develop fever and rash after admission to the hospital will most commonly have drug
reactions, staphylococcal bacteremia from central lines, systemic lupus erythematosus (SLE),
or postoperative TSS.
The traditional approach to the patient with fever and rash is based on the characteristic
appearance of the rash (2,3). The most common types of rash include petechial,
maculopapular, vesicular, erythematous, and nodular. Although there can be overlap in
presentation, most causes of fever and rash can be grouped into one specific form of cutaneous
eruption (3).
A systematic approach requires a thorough history that includes patient age, seasonality,
travel, geography, immunizations, childhood illnesses, sick contacts, medications, and the
immune status of the host. A detailed history, physical exam, and characterization of the rash
will help the clinician reduce the number of possible etiologies. Appropriate laboratory testing
will also assist in delineating the cause of fever and rash in the critically ill patient.

History
A comprehensive history of the events leading up to the development of fever and rash is
essential in the determination of the etiology of the illness. Several initial questions should be
answered before taking a complete history (4,5).

1. Can the patient or someone who is with the patient provide a history?


2. Does the patient require cardiopulmonary resuscitation?


3. Are special isolation precautions needed?
   For example, patients with meningitis due toNeisseria meningitidiswill need
   droplet precautions, while patients withVaricellainfections will need airborne and
   contact precautions (Table 2). Health care workers should always exercise universal
   precautions. Gloves should be worn during the examination of the skin whenever an
   infectious etiology is considered.


4. Are the skin lesions suggestive of a disease process that requires immediate antibiotic
   therapy?
   Patients with infections suggestive ofN. meningitidis, RMSF, bacterial septic
   shock, TSS, orV. vulnificuswill need urgent medical and possibly surgical treatment
   to improve their chance of survival.


5. Does the patient have an exotic disease due to travel or bioterrorism?