What is the diagnosis and treatment for fever, abdominal pain, cough, and a rash?

Diagnosis and Management of Fever with Abdominal Pain, Cough, and Rash

This presentation requires immediate evaluation for infectious causes, with the differential diagnosis guided by rash morphology, travel history, and associated symptoms—prioritizing life-threatening conditions like meningococcemia, rickettsial diseases, and viral hemorrhagic fevers.

Critical Initial Assessment

Obtain specific travel history within the past 21 days, freshwater exposure, animal contacts, new medications, and sick contacts immediately 1, 2. The combination of fever, abdominal pain, cough, and rash suggests either:

• A systemic viral infection (most common)
• A bacterial infection requiring urgent treatment
• A parasitic infection if travel history is positive
• Drug reaction or autoimmune disease

Rash Characterization Determines Urgency

Examine the rash morphology and distribution pattern first, as this narrows the differential diagnosis significantly 3, 4, 5:

Petechial/Purpuric Rash (HIGHEST PRIORITY)

• Suspect meningococcemia immediately—this is life-threatening and requires emergent empiric antibiotics before diagnostic confirmation 6, 5
• Also consider rickettsial diseases, viral hemorrhagic fevers, or thrombocytopenia from dengue 6, 1

Maculopapular Rash

• Most commonly viral infections (measles, rubella, roseola, enterovirus) 3, 4, 5
• Consider drug reaction if new medications started within 1-3 weeks 2, 5
• Evaluate for Kawasaki disease if child with prolonged fever >5 days 3

Urticarial Rash with Fever

• If recent freshwater exposure in endemic areas, suspect Katayama syndrome (acute schistosomiasis)—check eosinophil count 1
• Consider drug hypersensitivity or serum sickness 4, 5

Essential Diagnostic Workup

Order these tests immediately 1, 5:

• Complete blood count with differential (check for eosinophilia >0.45 × 10^9/L suggesting parasitic infection, thrombocytopenia suggesting dengue, or atypical lymphocytes) 1, 7
• Blood cultures before antibiotics if bacterial infection suspected 6, 5
• Chest radiograph to evaluate for pneumonia given cough 6
• Liver function tests if hepatosplenomegaly or jaundice present 1

If travel to tropical areas within 1 year: malaria film and rapid diagnostic test mandatory 1

Specific Clinical Scenarios

Scenario 1: Child with Gradual Onset, Pruritus, GI Symptoms

Consider enterobiasis (pinworm) if:

• Intense nocturnal perianal itching present 8
• Abdominal pain, diarrhea, weight loss, irritability 8, 9
• Most common in children aged 5-14 years 8, 9

Diagnosis: Cellophane tape test (adhesive tape on perianal skin examined microscopically for ova) 8, 9

Treatment: Albendazole 400 mg single dose OR mebendazole 100 mg single dose, repeated in 2 weeks 8, 9

Scenario 2: Recent Tropical Travel with Urticarial Rash

Suspect Katayama syndrome (acute schistosomiasis) if:

• Freshwater exposure 2-9 weeks prior in endemic areas 1
• Fever, urticarial rash, eosinophilia, hepatosplenomegaly 1

Do not delay treatment waiting for serology—it may take up to 6 months to become positive 1

Treatment: Praziquantel 40 mg/kg single dose, repeated at 6-8 weeks, plus consider prednisolone 20 mg/day for 5 days for acute symptoms 1

Scenario 3: Severe Headache, Myalgia, Nonproductive Cough

Consider Q fever pneumonia if:

• Severe headache, myalgia, arthralgia with fever 6
• Nonproductive cough in 50% of cases 6
• Maculopapular or purpuric rash in 5-21% 6
• Fever lasting median 10 days (range 5-57 days) 6

Treatment: Doxycycline—fever resolves within 72 hours in majority 6

Scenario 4: Abrupt Onset High Fever, Respiratory Symptoms

Consider bioterrorism agents if epidemiologically suspicious 6:

• Inhalational anthrax: widened mediastinum on chest X-ray, gram-positive bacilli on blood culture 6
• Pneumonic plague: mucopurulent sputum with gram-negative rods, bronchopneumonia on chest X-ray 6
• Smallpox: vesicular/pustular rash most prominent on face and extremities, all lesions at same stage (unlike varicella) 6

Critical Pitfalls to Avoid

Do not assume viral etiology without excluding life-threatening bacterial infections 5. The following require immediate empiric treatment:

• Petechial rash = meningococcemia until proven otherwise 6, 5
• Fever with abdominal pain in elderly may have normal labs despite serious infection 6
• Neutropenic patients may have masked signs of abdominal sepsis with high mortality 6

In pregnant women with fever and rash, Q fever infection requires antibiotic treatment to prevent miscarriage, stillbirth, or premature birth 6

Children often have milder symptoms than adults but can still have severe disease—rash is more common in pediatric cases (up to 50%) 6, 3

Consider multiple concurrent infections in returning travelers—up to 28% have more than one infection 1

Empiric Management Algorithm

1. If petechial rash present: Start empiric antibiotics immediately for presumed meningococcemia 6, 5
2. If recent tropical travel: Empiric treatment for schistosomiasis if clinical suspicion high, even with negative initial serology 1
3. If severe pneumonia with systemic symptoms: Consider Q fever and start doxycycline 6
4. If gradual onset in child with GI symptoms and pruritus: Treat empirically for enterobiasis 8, 9
5. If no clear infectious etiology and new medications: Consider drug reaction and discontinue offending agent 2, 5

Most fever-rash syndromes are self-limited viral infections 3, 2, but the priority is identifying and treating the minority that are life-threatening or have long-term consequences 3.