A Case of Rash with Fever

LM Parsons
Division of Dermatology
Feb 2014



Provide an approach to a patient presenting
with rash and fever
Underscore the importance of the history in
making this diagnosis
Discuss the meaning of a photo-distributed
eruption

This is a 16 year old student with a long
history of RA just moved to Calgary from BC

Arthritis has been flaring and she has missed
most of the school year

Moved closer to Calgary for closer access to
her rheumatologist

No skin problems until 2 weeks prior when
she developed a fever (40 degrees) and began
c/o a sore throat and then swollen glands
under her neck and in her axilla and groin

Seen in ER on day 2 and prescribed
amoxicillin which she took for 3 days




The following day, she began to develop an itchy
rash, which was 3 days after the fever began
Rash began with swelling around eyes and then
noted on central chest, spreading up to face,
proximal and then distal arms. Involvement of
torso followed then legs, all over a 3 day period
over a 3 day period.
Rash evolved from pruritic to painful over 7 days
Defervesce occurred on day 10



Rash described by K and family as itchy then
painful
Fingers swollen but hard to tell if this was her
arthritis or the rash
No suspected aggravating or relieving factors

PMHX
 RA type arthritis
 Diagnosed Strep Pharyngitis in ER

Meds
▪ Sulfsalazine begun 3 months before with a dose adjustment 2
weeks prior
▪ Plaquenil Dose unchanged for 15 months
▪ Amoxicillin – DC’d on day 5 of the fever


Family History – non contributory
No significant travel history
 Cutaneous
▪ morbilliform rash
▪ periorbital swelling but not photo-distributed
▪ no conjunctival involvement
▪ Palms and soles clear
▪ No nail fold changes
 MSK
▪ Painful swelling of joints of both hands and some of her
toes
▪ Pain on movement of her left hip which restricts ROM
 Lymphoreticular
▪ Palpable lymphadenopathy in right submandibular and
left groin. ( causing the left hip pain)
▪ Hepatomegaly determined to be present and was
tender on palpation

Why is the absence of a photo-distribution
important in this case of rash and fever?
A.
B.
C.
A rash which exacerbates in areas of old sun
damage
A rash which appears on the skin only when
the patients goes outside
A rash which is found on skin in areas which
are not photo-protected
A.
B.
C.
A rash which exacerbates in areas of old sun
damage
A rash which appears on the skin only when
the patients goes outside
A rash which is found on skin in areas which
are not photo-protected
A.
B.
C.
D.
E.
Rheumatologic cause
Infectious etiology
Drug
Leukemia/Lymphoma
All of the above
A.
B.
C.
D.
E.
Rheumatologic cause
Infectious etiology
Drug
Leukemia/Lymphoma
All of the above





Blood work shows a WBC of 18 with a left
shift and eosinophilia
LFTs show increases in LDH and AST
Monospot is positive
Blood Culture –ve
Throat swab done in ER before the antibiotics
is also –ve



Hepatitis screen –ve
Autoantibody screen –ve except for RF which
was unchanged from 6 months previously
CRP only slightly elevated
A.
B.
C.
D.
E.
Rheumatologic cause
Infectious etiology
Drug
Leukemia/Lymphoma
All of the above
A.
B.
C.
D.
E.
Rheumatologic cause
Infectious etiology
Drug
Leukemia/Lymphoma
All of the above
A.
B.
C.
D.
No - urticaria are evanescent lesions seldom
lasting more than 24 hours
No - urticaria have as a primary lesion, small
discrete papules
Yes - urticaria are always associated with
eosinophilia
Yes - urticaria have eye involvement as a
possible sequelae
A.
B.
C.
D.
No - urticaria are evanescent lesions seldom
lasting more than 24 hours
No - urticaria have as a primary lesion, small
discrete papules
Yes - urticaria are always associated with
eosinophilia
Yes - urticaria have eye involvement as a
possible sequelae
A.
B.
C.
D.
E.
F.
Toxic erythema
Toxic epidermal necrolysis
Steven Johnson’s syndrome
DRESS
AGEP
Amoxicillin rash in a case of Infectious
Mononucleosis
A.
B.
C.
D.
E.
F.
Toxic erythema
Toxic epidermal necrolysis
Steven Johnson’s syndrome
DRESS
AGEP
Amoxicillin rash in a case of Infectious
Mononucleosis
A.
B.
C.
Amoxicillin
Sulfasalazine
Plaquenil
A.
B.
C.
Amoxicillin
Sulfasalazine
Plaquenil

70% of patients will have elevated transaminases and hepatomegaly

This may persist for months

The hepatitis is often anicteric and without
cholangitis.
11% of DRESS patients will exhibit renal
disease
 Allopurinol is the most common drug
followed by carbamazepine and dapsone


Pulmonary
 Minocycline is the most common drug causing lung
pathology

Cardiac
 Myocarditis- potentially fatal and can present
months after withdrawal of the offending drug and
resolution of the clinical and laboratory abnormalities
 Ampicillin and minocycline are the most commonly
implicated drugs



Provide an approach to a patient presenting
with rash and fever
Underscore the importance of the history in
making this diagnosis
Discuss the meaning of a photo-distributed
eruption
A.
B.
C.
D.
Yes – There are target lesions and mucosal
involvement in this patient
Yes - Ocular edema without conjunctival
involvement is a prominent feature of SJS
Yes- Fever is a prominent feature of SJS
No – the clinical picture is not that of SJS
A.
B.
C.
D.
Yes – There are target lesions and mucosal
involvement in this patient
Yes - Ocular edema without conjunctival
involvement is a prominent feature of SJS
Yes- Fever is a prominent feature of SJS
No – the clinical picture is not that of SJS
A.
B.
C.
D.
Sulfa drugs
Ampicillin
Allopurinol
Carbamazepine
A.
B.
C.
D.
Sulfa drugs
Ampicillin
Allopurinol
Carbamazepine
immediate cessation of the causative medication(s). In cases in which the culprit drug is not
obvious,
clinicians must use their clinical judgment to select which medication to discontinue. They may
also utilize
patch or lymphocyte transformation tests to aid in identification when appropriate. Topical
corticosteroids
can be used for symptomatic relief, but systemic steroid therapy is generally required. Other
immunosuppressants
have also been employed in treatment and show promise in future therapy. Patients with
DRESS syndrome should be managed in an intensive care or burn unit for appropriate care and
infection
control. In addition, appropriate specialists should be consulted based on the affected organ
systems. Most
patients recover completely after drug withdrawal and appropriate therapy. However, some
patients with
DRESS syndrome suffer from chronic complications and approximately 10% die, primarily from
visceral
organ compromise. Controlled clinical trials investigating the most appropriate therapies and
their risks,
particularly intravenous corticosteroids, are lacking, and would be invaluable in determining
the optimal