● Medications ● Immunizations and history of childhood illnesses ● Immune status of the host Features of the rash are also important to consider, including: ● Characteristics of the lesions ● Distribution and progression of the rash ● Timing of the onset in relation to fever ● Change in morphology, such as papules to vesicles or petechiae ● Symptoms associated with the rash (e.g., pain, pruritus, numbness) NP Consideration: Immunization History Inadequately immunized individuals are susceptible to traditional childhood viral infections and serve as a reservoir of disease. Recommended immunizations for children in the U.S. include hepatitis A and B; diphtheria, tetanus, and pertussis; Haemophilus influenzae type b; rotavirus; poliovirus; measles- mumps-rubella; varicella; influenza; human papillomavirus; pneumococcus; and meningococcus (Lopez & Sanders, 2021). The majority of these immunizations are reinforced when the individual enters college. Similarly, zoster vaccination is recommended for adults 50 years of age and older to decrease the incidence of zoster and postherpetic neuralgia. Self-Assessment Quiz Question #4 What are some clinical clues that can help distinguish Rocky Mountain spotted fever from meningococcemia, and why is travel history an important factor to consider in the diagnosis of this disease? a. History of recent antibiotic use, relative leukocytosis, and low platelet count; travel history indicates potential exposure to ticks carrying Rickettsia rickettsii b. Rapid onset of fever, headache, and stiff neck; travel history indicates potential exposure to ticks carrying Borrelia burgdorferi c. Petechial rash, relative leukopenia, elevated aminotransferases, and history of tick bites or travel to endemic areas; travel history is important because RMSF is endemic in certain regions d. Purpura and hemorrhagic necrosis, high fever, and rapid progression to septic shock; travel history is not a relevant factor in RMSF diagnosis
and rash. These occur in children, are generalized, and can last up to 2 weeks. Petechial lesions can also be seen in influenza and enteroviral infections when generalized (Vedak & Burgin, 2022). Tiny petechiae of the face, neck, and chest can be caused by prolonged straining during activities such as coughing, vomiting, giving birth, and weightlifting. Signs and Symptoms
● Viral rashes usually have small pink spots ● Usually start on the chest, stomach, and back ● Fever ● “Not acting right” for a few days
● Arthralgia ● Headache ● Lymphadenopathy
As mentioned earlier, a systematic and methodological approach is crucial for establishing a timely diagnosis, determining early therapy when appropriate, and considering isolation of the individual if necessary. Epidemiologic clues are important to pursue, such as:
● Age of the patient ● Season of the year ● Travel history ● Geographic location
● Exposures, including to insects (especially ticks and mosquitoes), animals (both wild and domestic), and ill contacts Rocky Mountain spotted fever Rocky Mountain spotted fever (RMSF) is a tickborne disease caused by Rickettsia rickettsii . After an incubation period of as little as 2 days, fever, headache, malaise, conjunctival suffusion, and myalgia usually develop. A rash appears in most people within the following week, initially on the wrists and ankles and later on the palms of the hands and soles of the feet, before spreading centripetally to include the arms, legs, face, and trunk (Lopez & Sanders, 2021). Travel history where RMSF is endemic is important to note. The organism is endemic in North, Central, and South America, especially in the southeastern and south- central U.S. (Patel, 2021). The rash is at first erythematous and maculopapular. Progression to a petechial rash is often noted, and in severe cases of RMSF, purpura and hemorrhagic necrosis can occur. Associated thrombocytopenia can make RMSF difficult to distinguish from meningococcemia. However, several clinical clues favor a diagnosis of RMSF, including a history of tick bites or visits to areas where RMSF-associated ticks are present, the occurrence of the rash a median of 3 to 4 days following the onset of fever, relative leukopenia, and elevated aminotransferases (Lopez & Sanders, 2021).
Figure 5. Rocky Mountain Spotted Fever
Centers for Disease Control and Prevention. (n.d.). 1962. https://phil. cdc.gov/Details.aspx?pid=1962. In public domain.
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