Derm emergencies— detecting early signs of trouble

When a returning traveler presents with a rash and systemic symptoms, it is important to take a thorough history and to consider infections endemic to the area visited. RMSF may initially be localized to the wrists and progress to widespread petechiae over hours to days. Because the cutaneous findings may not be as fulminant—and up to 10% of patients with RMSF have no rash at all³⁴—attention to the noncutaneous features is important. Fever, headache, neurologic symptoms, joint complaints, and abdominal pain (or only a few of these manifestations) in the context of potential tick bite exposure should prompt consideration of RMSF.³⁵

Keep in mind, too, that in cases of fulminant infections such as meningococcemia and DIC, the hallmark purpura fulminans may not be present initially.³⁶ Although the initial cutaneous findings may be subtle, however, such patients will appear quite ill, and their condition will deteriorate rapidly. Because prompt antibiotic therapy can save life and limb, a high index of suspicion should be maintained for any patient who presents with a rash in the setting of fever and hypotension or other evidence of shock.