From the Guidelines
The next steps for investigating a patient with headache, fever, and rash should prioritize stabilizing their airway, breathing, and circulation, followed by a thorough history and physical examination, and appropriate laboratory and imaging studies, as outlined in the UK Joint Specialist Societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1. The patient's condition should be assessed using the National Early Warning Score, with an aggregate score of 5/6 or a score of 3 in any single physiological parameter prompting an urgent review by a clinician competent to assess acutely ill patients, and a score of 7 or more prompting an urgent assessment by a team with critical care competencies 1. Key laboratory tests should include:
- Blood tests: complete blood count, comprehensive metabolic panel, C-reactive protein, erythrocyte sedimentation rate, and blood cultures
- Specific serological tests for infectious diseases like meningococcemia, Rocky Mountain spotted fever, measles, rubella, and Zika virus, based on exposure history and geographic location
- Cerebrospinal fluid analysis via lumbar puncture, examining for cell count, glucose, protein, culture, and PCR testing for viral and bacterial pathogens, if meningitis is suspected Imaging studies, such as a head CT or MRI, should be considered if there are neurological symptoms or signs of increased intracranial pressure 1. Empiric antimicrobial therapy may be warranted while awaiting results, typically with ceftriaxone 2g IV every 12 hours plus vancomycin 15-20 mg/kg IV every 8-12 hours for suspected bacterial meningitis, as recommended by the ESCMID guideline on the diagnosis and treatment of acute bacterial meningitis 1. It is essential to consider the broad differential diagnosis of fever and rash, including tickborne rickettsial diseases, viral exanthemas, and other illnesses, and to initiate empiric treatment early to prevent poor outcomes, as highlighted in the MMWR Recommendations and Reports on the diagnosis and management of tickborne rickettsial diseases 1.
From the Research
Next Steps for Investigation
The next steps for investigating a patient with headache, fever, and rash involve a combination of clinical evaluation, laboratory tests, and imaging studies.
- The patient's history and physical examination are crucial in determining the underlying cause of the symptoms, as certain historical and examination findings increase the likelihood of a secondary headache disorder and the need for diagnostic testing 2.
- Laboratory tests such as blood tests and cerebrospinal fluid (CSF) examination can help diagnose conditions like meningitis, which is characterized by fever, headache, and meningismus 3, 4.
- Imaging studies like magnetic resonance imaging (MRI) or computed tomography (CT) scans may be necessary to rule out other conditions like subarachnoid hemorrhage or brain tumors 2.
- The type of rash can also provide clues to the underlying diagnosis, with different types of rashes associated with different conditions, such as petechial, maculopapular, vesicular, erythematous, and urticarial 5.
- In patients with a history of travel to endemic countries, the possibility of infectious diseases like murine typhus should be considered, especially if the patient presents with headache, fever, and maculopapular rash 6.
Diagnostic Considerations
- The diagnosis of bacterial meningitis is typically confirmed by CSF examination and culture, which shows an elevated neutrophil count, elevated protein, depressed glucose, positive Gram stain, and growth of the bacteria on appropriate culture media 3.
- Aseptic meningitis, on the other hand, is characterized by increased protein and white count in the CSF, with negative Gram stain and cultures 4.
- The presence of fever, headache, and rash can also be indicative of other conditions like viral infections, autoimmune disorders, or allergic reactions, which require careful evaluation and diagnosis 5.