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occur anywhere on the body and is less commonly seen on the palms and/or soles Vasculitis is less prominent, and leukopenia, anemia, and hepatitis are more common in ehrlichiosis than in RMSF As for RMSF, doxycycline is the drug of choice for therapy in patients of all ages and at the same dose of mg/kg/day in divided doses (maximum 100 mg twice a day) Therapy is continued until the patient is afebrile for at least to days and for a minimum total course of to 10 days Clinical improvement is usually apparent within days, and if not, an alternative diagnosis should be sought Disease may be more severe or even fatal in untreated patients Early initiation of therapy minimizes morbidity and mortality Dengue Fever Dengue fever is caused by four dengue viruses transmitted by Aedes mosquitos and is seen in tropical and subtropical areas of almost all continents (including areas of Puerto Rico and the Caribbean basin and now in Florida) Many cases are asymptomatic In symptomatic cases, initial constitutional symptoms include sudden onset of high fever, severe headache, myalgia, arthralgia, and abdominal pain During the course of fever that lasts to days, back and leg pain may be severe, hence, the disease’s nickname “break bone fever.” The development of a hemorrhagic vasculitis, most common in patients younger than 15 years, leads to the more concerning subtype called dengue hemorrhagic fever The term dengue shock syndrome is used in even more severe cases when increased vascular permeability leads to shock Encephalopathy, hepatitis, myocardiopathy, intestinal bleeding, and pneumonia are other complications Two distinct rashes may be seen, which coincide with the disease’s biphasic fever pattern The first rash is a generalized, transient, macular rash that blanches under pressure and is seen within the first 24 to 48 hours of the onset of systemic symptoms The second rash coincides with or occurs to days after defervescence and is generalized morbilliform, sparing the palms and soles Diagnosis is based on clinical suspicion and potential exposure based on the virus’s geographic distribution Serologic testing is available as is viral isolation and measurement of serum immunoglobulin antibodies in paired serum specimens obtained weeks apart Treatment is supportive, and may require aggressive fluid management and pain control Intravenous immunoglobulin and/or plasma exchange may be of benefit in severe cases Causes of Other Widespread Rashes Associated With Fever Non–life-threatening illnesses associated with fever and widespread rash include coxsackievirus infections, erythema infectiosum, scarlet fever, and early varicella
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