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S2D: The Symptom to Diagnosis Podcast - Episode 37: Fever and Rash
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S2D: The Symptom to Diagnosis Podcast - Episode 37: Fever and Rash
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2023-06-03T00:00:00.0000000
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[upbeat intro music] [upbeat intro music] [upbeat intro music] [Dr. Cifu] I'm Adam Cifu. [Dr. Stern] And I'm Scott Stern. [Dr. Cifu] And we're here with another episode of S2D, the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms.
We begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge. The cases that we discuss are drawn from our clinical experiences, but because protecting patient privacy is part of our oath, we never discuss actual patients.
What are we talking about today, Scott? [Dr. Stern] Well, I'm actually a little bit afraid to say, but we're going to do fever and rash. And Adam, you are the expert of the day, do you have a case to present to me? [Dr. Cifu] I do have a case to present to you. [Dr. Stern] Okay. [Dr. Cifu] It's a good one too. [Dr. Stern] Oh boy.
[Dr. Cifu] I don't think you're going to get it. [Dr. Stern] I don't think I'm going to get it either, - but go ahead. - [Dr. Cifu chuckles] [Dr. Cifu] Okay, so this is a 45-year-old man who comes in with fever and a rash. He was well until about six days before presentation when he abruptly developed fever, rigors, myalgia and severe headache. He figured it was just the flu, and he took to bed for a couple of days.
I love it when people take to bed. Two days before presentation, he began actually feeling a little bit better, but then took a turn for the worse about 24 hours later. And on presentation, besides the fever, myalgias, headache, he also had a macular rash, mostly on his trunk, and he had really quite striking conjunctival erythema and he had really quite striking conjunctival erythema or suffusion as they call it, sort of almost edema of his conjunctiva.
He also had lower extremity edema, he had ARDS, he had transaminases in like the 8-900 range, and AKI. in like the 8-900 range, and AKI. I admitted this guy to the intensive care unit. This is going back a long time, I was a resident at the time. He was intubated, placed on broad spectrum antibiotics. And so I guess I throw out to you, what do you think?
[Dr. Stern chuckles] Well, I think I'm terrified, you know, you're presenting someone with a diffuse - inflammatory syndrome- - [Dr. Cifu] Yeah. [Dr. Stern] -he has multi-organ failure, essentially, that's developed very rapidly, and so it's quite concerning. I mean, top of my list would obviously be infectious categories and I'd like to know if he's traveled, or has been immunocompromised, because obviously travel would really change the epidemiology of what would be possible.
I suppose it's possible it's and acute immunologic reaction to something. We can find out about his past medical history, see if he has any past medical history or family history of any of the collagen vascular diseases. Those would be the top two things on my list. Has he- Can you tell me those things? [Dr. Cifu] Yeah, so he's a pretty healthy guy. He worked for the local transit authority, mostly on the local trains, sort of subway and light rail.
mostly on the local trains, sort of subway and light rail. He saw a doctor about yearly, but really had nothing else going on. No risk factors for immunosuppression, was on no medications. [Dr. Stern] And travel? [Dr. Cifu] No, not even no recent travel, no significant travel in decades. [Dr. Stern] Well, that's too bad because- [both chuckle] [Dr. Stern] -if he had traveled, there would be a series of things that are a little bit more common overseas, like dengue fever and whatnot- [Dr. Cifu] Sure, sure.
[Dr. Stern] -that could present like this. Without that, you know, you'd got to think first, I suppose what I think about first are the life-threatening infections that can present with multi-organ failure and rash. You know, Neisseria meningitidis certainly comes to mind, although that's classically a petechial rash, pneumococcus can present with overwhelming sepsis and a rash, toxic shock syndrome, endocarditis.
Rickettsial diseases can do this, you know, but it doesn't sound like the rash of either Lyme or Rocky Mountain spotted fever, the way you've described it. And then a whole host of viral infections acute HIV, I believe measles could even present like this. Hepatitis B, boy, West Nile virus, but I have to say, I really don't know which one of those I would put very highly, I mean, it's pretty terrifying.
I've never said this before on a podcast, but I'd get somebody else to help me right away, including an infectious disease expert. [Dr. Cifu chuckles] Sounds good, sounds good. We can stop there. I can tell you, on initial evaluation besides everything I've told you already, you know, terribly abnormal chest X-ray, liver function abnormalities, acute kidney injury.
You know, we cultured everything there was to culture. Those initially were negative and he had a pretty rocky course. We actually were able to get a diagnosis eventually, but I'll get to that in the future. [Dr. Stern] Oh my goodness. Okay, well, I'm sure I was wrong, but I'll be eager to learn from you. Go ahead. [Dr. Cifu] Maybe just two things, which you noted to, I don't know, sort of underline, highlight.
You mentioned West Nile virus. When you put that on our notes for the episode, I looked that up. I actually didn't know that that came with a rash and it turns out about 16% of people have kind of, usually a macular, kind of a non-specific viral exanthem type rash. And you said this didn't sound to you like the rash of Rocky Mountain spotted fever.
Can I ask you why? Because you're right. [Dr. Stern] Well, Rocky Mountain spotted fever often has more of a vasculitic picture. So, you know, if you see petechiae, and I suspect you'll talk about this, you have to distinguish whether it's petechiae or palpable purpura. You know, if it's palpable purpura that suggests that the vessels themselves are inflamed and you often see that in Rickettsial diseases, you see that in meningococcemia, although initially it can just look petechial, but you're really describing more of an- What I'm hearing you say is more of a macular rash.
So I'm saying it doesn't sound purpuric, it doesn't sound palpable, it doesn't sound like that. [Dr. Cifu] All true. And also the rash of Rocky Mountain spotted fever classically starts peripherally. So, hands and feet, often palms and soles, and then actually migrate centrally, while this guy kind of has the opposite, mostly central, right? [Dr. Stern] Right, although probably both of us for Neisseria and Rocky Mountain spotted fever, you're going to treat first and figure out later with this, because if you miss those, then the person dies for sure.
[Dr. Cifu] Which is different for you, because usually you evaluate first, then think later. [Dr. Stern] This one scares me, this one really scares me. I got to tell you people die with this. [Dr. Cifu] Okay. [Dr. Stern] All right, so I understand that you have five points for us about diagnosing fever and rash. [Dr. Cifu] I do have five points- - [Dr. Stern] All right. - [Dr. Cifu] -and five points here is a little bit like five points from the last podcast, weakness.
You know, it's hard to arrange this into some sort of beautiful framework differential diagnosis. So I thought about, you know, how do I think about this? And I think about this by saying fever and rash is really hard, right? The differential diagnosis is basically endless. There are few to no fingerprints that are really going to lead you in one direction.
So the starting approach is to be a doctor and to talk about all the things that you've already talked about. So what are the clinical clues? Is the person sick or not, right? Is this someone who walks into your clinic looking great, or is this someone who crashes into the emergency room looking terrible? Is there other organ involvement, right?
This guy's got ARDS, you know, maybe shock, liver shock, kidney, whole bunch of other things going on. What does the rash look like? As we'll talk about it a little bit later, you know, it's really uncommon that these rashes are sort of diagnostic or pathognomonic, but actually getting a sense for where the rash started, what kind of a rash it is, can help.
And then where are you, like, where are you practicing? Where has the patient been? You know, us in Chicago, if someone comes in with, you know, a disseminated fungal infection, it's probably going to be histoplasmosis, and we never see, you know, coccidia or plague, things that someone who's, you know, maybe practicing in Albuquerque might actually see occasionally.
[Dr. Stern] Okay. So we need to think about where the person is, where the rash started, right? And a long list of possibilities, it sounded like. [Dr. Cifu] Great. [Dr. Stern] Now, what's your next pivotal point? [Dr. Cifu] So, my next pivotal point is just to go back to the classic rashes of childhood. And maybe this is just fun because it's medical history, okay? And they're numbered, right?
So first disease, measles, second disease, scarlet fever, third disease, rubella. - Fifth disease, - [Dr. Stern chuckles] [Dr. Cifu] -notice we skipped number four, is parvovirus B19, used to be called erythema infectiosum. is parvovirus B19, used to be called erythema infectiosum. That's, you know, the classic slap cheek - rash little kids get. - [Dr. Stern] Right, right.
[Dr. Cifu] You see it a lot in adults, and in adults often kind of viral prodrome with then rash, joint pain. It's the case I was actually going to give you for this, but it's actually the case, or one of the cases in the joint pain chapter, so I thought I'd hold it back from you. And then sixth disease is exanthema subitum, also called roseola infantum caused by human herpes virus 6B or 7, subitum meaning suddenly.
I think it disappears suddenly rather than start suddenly, but I don't really know. So Dr. Stern, do you know why there's no fourth disease? [Dr. Stern chuckles] I have no idea. [Dr. Cifu chuckles] I didn't know either, and I got confused as I was looking through this. I was like, wait, wait, what's the fourth disease? So, fourth disease was something called Dukes' disease and has nothing to do with Duke's criteria, like for endocarditis, but is now thought to be just a variant of scarlet fever, so we no longer use that.
Scarlet fever, second disease, fourth disease doesn't exist. [Dr. Stern] You know, it's funny. I used to see scarlet fever, you know, it's that sandpaper - sort of rash from strep- - [Dr. Cifu] Yeah. [Dr. Stern] -and in the old days the grandmothers would get - petrified, - [Dr. Cifu] Yeah. [Dr. Stern] -when you said Scarlet fever because even though - it's not rheumatic fever- - [Dr. Cifu] Yeah.
[Dr. Stern] -in the old days, strep throat killed people - before penicillin. - [Dr. Cifu] Ah, interesting. [Dr. Stern] And so the people who are really old and who remember the old strep throat are terrified when you would say that. [Dr. Cifu] Ah, interesting. Yeah, I guess not common, but not unheard of, right? Diseases, fever, rash in kids would be acute rheumatic fever, - right? - [Dr. Stern] Right.
[Dr. Cifu] Which has a rash. And Kawasaki's, something else - which is actually seen. - [Dr. Stern] Right. But that rash looks sort of different, - the Kawasaki's rash. - [Dr. Cifu] Yeah, yeah, yeah. [Dr. Stern] So none of these really sound as we think, I'm going to do something different and talk about the case as we go - a little bit. - [Dr. Cifu] Okay.
[Dr. Stern] So you've mentioned measles, so I was just reading the other day that for people vaccinated, the failure rate of the measles vaccine - is incredibly low. - [Dr. Cifu] Right. [Dr. Stern] So we can assume that he was vaccinated? [Dr. Cifu] Yes, he was vaccinated. [Dr. Stern] And it doesn't sound like the rash of scarlet - fever. - [Dr. Cifu] Right.
[Dr. Stern] And as best I know, parvovirus doesn't cause multisystem failure, correct? [Dr. Cifu] Absolutely not. [Dr. Stern] So none of these are really striking me as likely culprits for him not to say that we shouldn't think about them. - [Dr. Cifu] Right, right. - [Dr. Stern] Right? - Is that true? - [Dr. Cifu] Absolutely. [Dr. Stern] All right, so what's your third point?
[Dr. Cifu] So third point gets a little bit to what you talked about when you looked at the case, are must-not-miss rashes. So I sort of say, okay, you look at the whole patient, think of where you are, think of what you see, think of points that are really going to say, oh, I think I know what this is. And then I sort of took a turn and said, look just for interesting medical history, let's talk about the classic pediatric rashes.
And now let's say, boy, are there any rashes which I got to think of because if I miss them, they're going to kill somebody, okay? And so I think a lot of these, you mentioned, so meningococcemia, right? Can be seen in patients with meningitis, without meningitis, rash is often macular and then evolves to petechiae or purpura, classically sparing the palms and soles, right?
Again, as you say, needs to be treated. Yeah, you'll draw your cultures, you'll do your LP, but you're going to figure things out after you've already started broad spectrum antibiotics. Toxic shock syndrome, right? So exotoxin-produced toxic shock syndrome can be caused by Staph or Strep. The criteria here for the diagnosis for toxic shock is high fevers, temperature above 38.9 °C, hypotension, a desquamating rash, and involvement of at least three organ systems, okay?
Maybe makes you scratch your chin on our case. Rocky Mountain spotted fever you talked about, really generally an abrupt presentation, fever, terrible headache, conjunctival suffusion like we're seeing in our patient here, myalgias, usually like our patient here. We talked a little bit about the rash, usually begins peripherally before spreading centripetally.
And then I guess, because you got two internists in a room talking about fever and a rash, we got to mention endocarditis, right? Can be associated with a rash. You guys all know, splinter hemorrhages, janeway lesions, ulcer nodes, blah, blah, blah, blah, blah. But come on, endocarditis, you know, you're not using the rash to diagnose endocarditis.
[Dr Stern] You know, those are really scary things. I just want to make one more point about meningococcemia. When I was a resident, one of my fellow residents happened to have three different patients that had meningococcemia. All three of them came in walking and talking and all of them died. [Dr. Cifu] Oh God. [Dr. Stern] So even though they were recognized pretty quickly and treated pretty quickly, it is truly, truly an infectious emergency, as a matter of fact, in Great Britain, they made a policy that if a doctor was seeing a patient in the office with suspected meningococcemia, they were to give them penicillin in the office before they left the office to go to the hospital and they actually cut mortality down.
[Dr. Cifu] That's amazing. Very interesting. [Dr. Stern] All right. So next. [Dr. Cifu] Okay. So those are the must-not-miss. And then I'm going to go to the things that you will actually see. And then I feel like I've never gone a year without seeing at least one of these, and usually I'm seeing multiple of them. So, mononucleosis, right?
Usually EBV, young adults presenting with fever, malaise, sweats, anorexia, nausea, chills, sore throat, posterior cervical lymphadenopathy, a common and actually fairly specific finding, splenomegaly, and a macular rash, often, as we talked about on a previous podcast, after the administration of ampicillin. Parvovirus, we talked about above, common, especially common in adults presenting as an acute arthropathy.
You often see lymphadenopathy, arthritis, fever, and the rash, when present, is often described as first macular, and then sort of lacy, reticulated, and this one often spreads from the limbs to the trunk and buttocks. You know, both those obviously can have fever, zoster, right? Super obvious shingles, seldom with a fever, but can have a low grade fever.
Lyme disease, certainly. And then a couple, which I, well, one which I think of less is mycoplasma, but lots and lots of mycoplasma infections can have lots and lots of different rashes. You know, the kind of mild macular rash to even things as bad as Stevens-Johnson. And then of course we got to talk about COVID, right? A lot of rashes have been described with COVID, COVID toes probably being the first one and the thing that people talked about the most, which is kind of a pernio, chilblain kind of look hands and feet that go along with COVID.
[Dr. Stern] But not a diffuse rash, correct? [Dr. Cifu] No, no, no. So COVID toes, certainly not a diffuse rash, but there's also kind of the diffuse viral exanthem rash. [Dr. Stern] So they can. [Dr. Cifu] Yeah, and as far as the prevalence of that, I don't think we know, you know, hopefully five years from now we'll look back and say, this is the percent of people, you know, with COVID at various ages who get a rash with it.
[Dr. Stern] But I think you said this was someone you saw years ago, so we could pretty much take that - out of his differential. - [Dr. Cifu] Right, right. [Dr. Stern] So, I'm listening carefully and trying to think of what we've missed so far. And we still have the Rocky Mountain spotted fever, the Neisseria, but it still seems pretty unknown. [Dr. Cifu] Yeah. [Dr. Stern] Maybe he's got chikungunya, but anyway.
[Dr. Cifu] I've got a fifth and final point. - [Dr. Stern] Go for it. - [Dr. Cifu] Okay. Ready - for this? - [Dr. Stern] Yep. [Dr. Cifu] Collaborate. So fever and rash, as I said, is hard, and my experience has been that fever and rash is either something that I make the diagnosis in the office with no help or I'm lost. And it really takes, like, a village.
And thinking back as I was preparing this on the cases which, you know, either as an outpatient or as an inpatient, the people who've really helped with this are kind of not surprisingly are infectious disease, derm, and interestingly, nephrology are the people who come in and, like, everybody's talking together and someone kind of has the idea. Huh? We haven't talked about this. And we get all over that and eventually make a diagnosis.
Rheumatology would be the other group that, you know, certainly you'd think about, but just- And please, don't like, you know- The rheumatologist out there shouldn't @ me on Twitter about this, but you know, the rheumatologists have been less helpful to me over the years. [Dr. Stern chuckles] Okay. [Dr. Cifu] On this point. [Dr. Stern] All right, so you two are calling for help - at this point. - [Dr. Cifu] Yeah.
[Dr. Stern] So, I assume that you have some more information for us now? [Dr. Cifu] So the more information is this. So as I said, we had everybody working on this guy, okay? And after about, you know, over the first 24-36 hours, And after about, you know, over the first 24-36 hours, the idea from the kind of clinical presentation came up, that people agreed on more and more was that this was a pretty good presentation for leptospirosis.
And the one kind of exposure that this guy had was to a lot of rodents given track work that he did at work, okay? [Dr. Stern] Okay. [Dr. Cifu] And so now you can actually do PCR, at the time we were doing- [Dr. Stern] Convalescent antibodies? [Dr. Cifu] Convalescent antibody titers. And what was interesting about this is, we presented this case, we had, you know, these weekly ICU rounds where this amazing old, quite famous nephrologist came to listen to cases.
And I presented this case to him, and I was so excited because it was such a good case and we really thought we had an answer, and the guy sits back, scratches his chin, he goes, "Adam, let me ask you one question. Does this gentleman have a dog?" And I was like, "I can't believe it!" And it was like, the first thing he thought of. And it turned out that the guy's IgM came back positive, IgG negative.
And then fortunately he survived, had quite a rough course. We were able to have him come back, get convalescent titers, which made the diagnosis later. It was really an amazing case. [Dr. Stern] Wow. Well, I had a feeling I wasn't going to get that one. How do you treat that? [Dr. Cifu] Oh God, I don't remember it.
Some sort of broad spectrum antibiotics. I think you do a third-generation cephalosporin. [Dr. Stern] Ah, okay. But he survived? [Dr. Cifu] He did survive, yes. [Dr. Stern] Well, that's great because this is not the type of case where that's necessarily the story. [Dr. Cifu] No, absolutely not. Absolutely not. [Dr. Stern] Thanks for that. So let's go on to fingerprints, misconceptions and pet peeves and other random pearls of knowledge.
I actually wonder if they're random, but okay. So you want to start us off with some fingerprints? [Dr. Cifu] Yeah, so probably not really any fingerprints. I mean, you could kind of think of some specific diseases, which, you know, I think we've probably already beat to death on other podcasts. You know, the thing that came up to me was, was like mono, right?
So splenomegaly and palatable petechiae in someone who you think about mono, its likelihood ratio of 5 to 6, you know, vesicles and a dermatome, I have no idea what the likelihood ratio is, but let's say- - [Dr. Stern] 100. - [Dr. Cifu] Exactly. That's what I was going to say. [chuckles] [Dr. Stern] You know, the other interesting thing I looked up recently was mono with rash.
It turns out if somebody has a rash before they've had ampicillin, that's not very likely to be mono, the likelihood is something like 5% or something like that. [Dr. Cifu] When you give ampicillin, do you ever give it just to see if people get a rash and like keep them in your clinic overnight so you can observe them?
[Dr. Stern] No, I have a little ethical problem with that, but if you want to try that, let me know how that goes. All right. So, how about some common misconceptions? [Dr. Cifu] Okay, I kind of alluded to this before. It's maybe that the rash itself will be diagnostic. So often the rashes you see are just non-specific viral exanthems and are thus not that helpful, but I guess maybe to undermine my own common misconception, sometimes they are, right?
This is certainly the case with vasculitic rashes that really focus your differential diagnosis, or maybe systemic fungal infection, the rashes of systemic fungal infections, which might not be that specific in their appearance, but, you know, imagine someone who comes in, you know, fever, rash, lymphadenopathy, pulmonary infiltrates, and you're trying to make a diagnosis and maybe biopsying one of those lesions is kind of the easiest way to identify the causative agent.
[Dr. Stern] So let's just elaborate on that for me. [Dr. Cifu] Yeah. [Dr. Stern] So we're on a podcast so they can't see, we can't show pictures, but that will be the type of rash where you might see a little purple area, but you can feel it if you rub your finger over it, there's a bump associated with it, right? - [Dr. Cifu] Purpura. - [Dr. Stern] So that's a clue.
- Right. - [Dr. Cifu] Right, absolutely. [Dr. Stern] And that would suggest either a vasculitis of some sort, either an immune vasculitis or an infectious vasculitis. [Dr. Cifu] Absolutely. And there's a case maybe if you're seeing that, you know, infectious disease and rheumatology would be the people to have on board. [Dr. Stern] Right. Well, I didn't have any misconceptions, so we're going to go on- Except for my own, not knowing this case, but let's go onto pet peeves.
[Dr. Cifu chuckles] So my pet peeve is also- I really stretch the definitions on this podcast. This is intentionally to draw us a little bit away from infectious disease, which I think we've been kind of focusing on a lot so far. And so my pet peeve is, don't get too obsessed with infection, right? Some other things can certainly present with fever and a rash.
And I'm just going to throw out a couple from sort of, my clinical experience. So, localized rash plus a fever, DVT, superficial thrombophlebitis, right? Local rash, probably pretty obvious what it is, but those people can have a low grade fever. Gout, certainly, especially people who have, you know, a couple of contiguous joints who are really inflamed, and that could look like, you know, maybe a wrist and an elbow and a low grade fever for gout.
Erythema nodosum, right? Which can go along with a whole bunch of diseases, but sometimes you'll see people come in, fever, and they'll have those tender red nodules on their shins. And then if you're seeing someone with fever and a rash with a more generalized rash and thinking about non-infectious things, certainly lupus, cutaneous vasculitis, I guess that could probably go in either localized or generalized.
Drug reactions, right? Certainly people who present with like, Stevens-Johnsons, or TEN, and then a favorite of mine that we saw a case just about 18 months ago on service, which I think overlaps between drug eruptions and vasculitis on some sort of non-infectious fever-rash Venn diagram on some sort of non-infectious fever-rash Venn diagram is an ANCA-associated vasculitis that's associated with, I've always have trouble pronouncing this, levamisole, which is a common contaminant of cocaine.
And it causes this vasculitis, and so people can come in with like a vasculitic rash and an ANCA-associated vasculitis, and it's important to get the history of, that it's sort of, it's an exogenous insult rather than an autoimmune. [Dr. Stern] So the cocaine is contaminated with the levamisole? [Dr. Cifu] Yeah, and the drug is actually a veterinary drug, but I guess just because of what it looks like, it's a fine white powder, it's easy to get cheap, it's good to cut cocaine with.
And there was a time, and I think this is older rather than newer, where up to 70% of cocaine was actually contaminated with this agent. So it's not like you get this agent and you get a vasculitis. It's a very, very small percentage who gets this, but it's well-described. [Dr. Stern] So maybe my first pearl should be know where you're getting your cocaine from.
[both chuckle] [Dr. Cifu] Know where you're getting your patients from, know where you're getting your cocaine from, - all important things. - [Dr. Stern] Oh my goodness. Okay. So my actual first pearl, I mentioned earlier, you do have to really think about travel history. So let's just mention that briefly. When I think about travel and fever, not necessarily fever and rash, the two things that's come to mind most quickly are malaria and typhoid fever, and they both require urgent diagnosis and treatment.
Realize that typhoid fever, although it's caused by salmonella, is often not associated with diarrhea. Neither of those typically cause a rash, though, so they're not really pertinent to what we're talking about. [both chuckle] [Dr. Stern] Some of the other rashes that can be associated with fever and travel include dengue fever, which just really sounded a lot like multisystem failure, et cetera. That's in South and Central America, Southeast Asia, parts of Africa.
Chikungunya is more widespread, actually, I was surprised to see on a WHO map and should be something you think about. You know, fortunately we're not seeing Ebola right now, but you know, this would all be a good case, a good description of an Ebola infection, but fortunately, we don't have that on the map that I know of right now. [Dr. Cifu] And hopefully it'll be a very time-limited comment and this won't be foreshadowing, anything, but monkeypox.
- [Dr. Stern] Monkeypox. - [Dr. Cifu] Right? Fever, rash should be fine. Chikungunya always reminds me of just pre-pandemic, Chikungunya always reminds me of just pre-pandemic, you and I were in India and we were doing a teaching session. I don't even remember what the case was, I think it might have been joint pain, and we went through this whole differential and then we sort of opened it up to the group.
And one of the women in the class, a medical student or resident was like, "Well, this sounds like chikungunya." And the two of us were like, "Uh, yeah." - [Dr. Stern chuckles] Right. - [Dr. Cifu chuckles] [Dr. Stern] We were out of our league in that one. [Dr. Cifu] But maybe that underlines, you know, if there's travel, if there's fever and rash, boy, have your ID consultants there, if it's not something which you're seeing all the time, because, you know, you may work in a place that's loaded with immigrants, from an area who are constantly going back and forth or having family members come back and forth.
[Dr. Stern] All right. Agreed. Do you have a pearl for us? [Dr. Cifu] Sure. I'll go with the petechiae and purpura. We talked about these, I think both on our rash episode and certainly our bleeding episode. As a reminder, petechiae are mostly red, but can be blue or purple kind of pinpoint spots. Those are non-blanching. Purpura are larger blanching macules that may be palpable or not.
If you see these, you know, you should be concerned, especially, if they're in the setting of fever. And that's the time to say, boy, you know, let me think about infectious diseases that might be causing, you know, DIC and purpura, or let me think of rheumatologic diseases, which might be causing a vasculitis. [Dr. Stern] And you would also check their platelet count, of course, because thrombocytopenia can do that.
And my last pearl is what we've already beat to death, which is these bacterial infections. And this is something I have not said on the podcast before, but this is one time where I treat first, and then I think. Meaning, get everything started, and then keep thinking. [Dr. Cifu] Right. And my snide comment for us is that I think usually you just order workups and then you start thinking. [Dr. Stern] Well...
- [Dr. Cifu chuckles] - [Dr. Stern] Okay. [Dr. Cifu] I had to get that in. [Dr. Stern] Yeah, good. [Dr. Cifu] Okay, we hope you found this episode of the Symptom to Diagnosis podcast useful and a bit enjoyable. As a reminder, our textbook, Symptom to Diagnosis An Evidence-Based Guide, takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations.
The book is available in print, on your handheld device, and in a fully searchable mode via the AccessMedicine website available worldwide from McGraw Hill. The music for this, the S2D podcast, is courtesy of Dr. Maylyn Martinez. [upbeat outro music] [upbeat outro music] [upbeat outro music]