An 8-year-old boy accompanied by his mother presents to his PCP with a 4-day history of fever and rash
Chief Complaint
“Fever and rash.”
History of Present Illness
An 8-year-old boy accompanied by his mother presents to his PCP with a 4-day history of fever and rash. His mother states the illness began with a runny nose, cough, and pinkeye. The rash started yesterday on his head and spread to his trunk and lower extremities. The patient denies emesis, diarrhea, headache, and photophobia. He is eating and drinking and is intermittently playful. No discharge noted from the eyes. No sore throat or lesions noted by his mother on his lips or in his mouth. He does not have a rash on the palms or soles of feet. His mother states they returned from a family vacation to Europe about 10 days ago. The patient is homeschooled. No other family members or friends have similar symptoms.
Review of Systems
A ROS is positive for fatigue. It is negative for nausea, abdominal pain, blood in stool, or changes in urination. No chills or myalgias noted. No chest pain or SOB noted.
Relevant History
His mother was G1P1 and describes a normal pregnancy, labor, and delivery. The child has no surgical history or chronic medical conditions. He had a febrile seizure when he was 9 months old. He was seen in an ED for the seizure, and a subsequent workup was negative. He has had no further seizures. He received vaccines from birth to 6 months, but after the seizure, the mother refused vaccines, fearing they will trigger another seizure. The child lives with his parents and has no siblings. There is no family history of seizure disorders.
Allergies
No known drug allergies; no known food allergies.
Medications
None.
Physical Examination
Vitals: T 39.5°C (103.2°F), P 105, R 16, BP 98/59, HT 127 cm (50 in.), WT 25.4 kg (56 lbs), BMI 15.7.
General: Well appearing, appropriately responsive, in no acute distress.
Skin, Hair, and Nails: Erythematous, blanching macular-papular rash from hairline to toes. Coalesces on trunk. No petechiae. No involvement of palms or soles.
Eyes: Conjunctiva red bilaterally. No tearing or purulent discharge noted.
ENT/Mouth: Nose with erythematous turbinates and clear-yellow discharge. Post-nasal drip noted. No posterior oropharynx erythema or exudate. Small white spots on erythematous base noted on buccal mucosa. TMs pearly gray and mobile bilaterally.
Neck: Mild anterior cervical lymphadenopathy noted. No thyromegaly or tenderness to palpation.
Chest: No increased work of breathing. Mild cough noted.
Lungs: Breath sounds equal bilaterally. No wheezes, rhonchi, rales.
Heart: RRR. No murmurs noted. Peripheral pulses 2+ and equal.
Abdomen: Soft, non-tender, and non-distended. No hepatosplenomegaly noted.
Neurologic: A&O×3. No nuchal rigidity. Strength 5/5 for upper and lower extremities. DTR 2+ and equal bilaterally in the upper and lower extremities. Cranial nerves II to XII intact.
Pls response to Ms. S Discussion. Thank you.
DISCUSSION BOARD 2
Give 3 differential diagnosis.
Scarlet Fever
Scarlet fever is caused by a bacterial infection with group A Streptococcus. The bacteria are spread by inhalation of air that has been contaminated by the coughing or sneezing of an infected person. After exposure, the incubation period is between two and four days. The disease is characterized by a red, sore throat; fever; swollen lymph nodes; and a red, rough rash; it may follow throat infections and, occasionally, wound infection and septicemia (blood poisoning). The face is flushed, resembling sunburn with goosebumps, with a pale area around the mouth. The mucous membranes of the mouth, throat, and tongue become strawberry red. The irritation usually appears first on the upper chest but quickly spreads to the neck, abdomen, legs, and arms. Antibiotics have reduced the complications of scarlet fever to a minimum. A strep test, involving a simple swab of the throat, is used to confirm the diagnosis. In mild cases, recovery takes about seven days. To decrease its contagious effect, isolation for the patient for the first twenty-four hours starting antibiotics is recommended. A few days after the body temperature returns to normal, peeling off of the skin takes place at the site of the rash, especially on the hands and feet. A child with scarlet fever should rest and be given plenty of fluids and antipyretics (fever-reducing agents), such as acetaminophen, to reduce discomfort. A saltwater gargle, lozenges (for children over the age of four) and using a humidifier can help to alleviate the pain of a sore throat. The spread of infection can be greatly reduced with frequent and thorough handwashing and avoiding the shared use of utensils, drinking glasses, and linens.
I considered scarlet fever as one my differential diagnosis mainly because of the rash can be confused with other viral illness that can cause rashes such as measles and the fever. Another reason is that this childhood disease is most commonly seen between ages 2 and 8 years old which fits the age of the patient in the case scenario. I am ruling out this diagnosis because the main symptom of this illness is sore throat, red swollen tongue, and flushed cheeks as well as rashes that that first appear on the upper chest that quickly spreads to the neck, abdomen, legs and arms that peels off at the site of the rash especially on the hands and feet which this case study does not clearly support basing on the presenting symptoms. Another is reason that based on the clinical features of this case, it is more viral in nature unlike Scarlet Fever which is a bacterial infection that requires antibiotic as treatment.
German Measles (Rubella)
Rubella is sometimes referred to as the “German Measles” or “three-day measles”. It can be either acquired, infecting both children and adults, or congenital, infecting a fetus before birth. It is a contagious disease caused by a virus called Rubivirus in the Matonaviridae family. For children, the first symptom is typically a rash that is small, red, and spotty. It starts on the face and behind the ears and spreads downward in the next one or two days. This rash is much milder than the rash of measles. Forscheimer’s Spots pinpoint red macules and petechiae can be seen over the soft palate and uvula. The rash is preceded by symptoms that include a low-grade fever, headache, loss of appetite, mildly red eyes, a stuffy nose, a sore throat, coughing, and lymph node enlargement in the neck. Typically, this enlargement occurs behind the ears and in the back of the neck.
Although Rubella and Rubeola share similarities, they are considered separate disease. These similarities made me consider Rubella as one of my differential diagnoses. Both are caused by viruses that can result in skin rashes, upper respiratory symptoms such as runny nose and cough, fever, red eyes, and both can be prevented by vaccination called MMR thus history of travel outside the country while unvaccinated imposes higher risk of acquiring the virus, oral spots, cervical lymphadenopathy.
I am ruling out this differential diagnosis based on the clinical presentation of the patient in this case. The patient has history of 4-day history of rash and high-grade fever (39.5 C), per mom’s statement that the illness began with a runny nose, cough, and pinkeye, development of rash from hairline to trunk to lower extremities, small white spots on erythematous base on the buccal mucosa, mild anterior cervical lymphadenopathy in contrary with the presentation of Rubella. Rubella’s first symptom is rash that lasts 3 days that starts on the face and spreads cephalocaudally, the presence of Forscheimer’s Spots pinpoint red macules and petechiae can be seen over the soft palate and uvula plus posterior cervical lymphadenopathy. These symptoms clearly differentiate Rubella vs Rubeola.
Measles (Rubeola)
Measles is one of the most contagious infections to affect humans. The virus is spread through airborne droplets or by direct inoculation through the nose, mouth, or eyes after touching an infected surface. People with measles can spread the virus starting about 4 days before the onset of rash through 4 days after their rash appears. Common symptoms of measles are fever, cough, runny nose, red and watery eyes (conjunctivitis), and rash. Small white spots (Koplik spots)typically appear on the inside of the cheek 2 to 3 days before the rash starts. The measles rash consists of flat red spots that spread from the head to the lower extremities. Measles can cause pneumonia, ear and upper airway infection, pain and sores in the mouth, and diarrhea. Rare but serious neurologic complications include swelling of the brain and spinal cord or progressive neurologic disorders that develop weeks to years after measles infection. People at highest risk of developing complications from measles include unvaccinated individuals younger than 5 years or older than 20 years and those who are immunocompromised or pregnant. Measles acquired during pregnancy can result in preterm labor and low infant birth weight.
I am ruling in Measles (Rubeola) due to the presence of similar clinical features that is being manifested on the patient on the case discussion including the following. Mainly fever, cough, runny nose, conjunctivitis, small white spots on the buccal mucosa, mild anterior lymphadenopathy, erythematous, blanching macular-papular rash from hairline to toes, as well as travel history and not fully vaccinated highly suggest that Measles (Rubeola) is to be considered as primary diagnosis.
What is the most likely diagnosis. Explain how you arrived with your diagnosis.
The most likely diagnosis is Measles (Rubeola) due to the presence of Koplik spots described as small white erythematous spots on buccal mucosa followed by erythematous, blanching macular-papular rash from hairline to toes which have been regarded as a pathognomonic feature of measles (Rubeola). Other symptoms which strongly support this diagnosis that is also clinically present in this case scenario are the high-grade fever of 39.5, and the 3 C’s namely, cough, coryza, conjunctivitis that our patient have. Another reason why I have arrived with this diagnosis is due to the recent travel to Europe 10 days ago with an incomplete vaccination which makes this patient on a higher risk of acquiring Measles (Rubeola).
Outbreaks in countries to which Americans often travel can directly contribute to an increase in measles cases in the United States. In recent years, measles importations have come from frequently visited countries, including, but not limited to, the Philippines, Ukraine, Israel, Thailand, Vietnam, England, France, Germany, and India, where large outbreaks were reported.
Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis.
Measles (Rubeola) is a highly contagious viral disease characterized by a maculopapular (pimply) rash that develops on the skin and spreads rapidly over much of the cutaneous surface of the body. Measles virus is classified with the paramyxoviruses, a class of viruses in which ribonucleic acid (RNA) serves as the genetic material.
Exposure generally follows an oral-oral means of transmission, as the person inhales contaminated droplets from an infected individual. The incubation period for active measles ranges from seven to fourteen days. During this early stage, the infected individual becomes increasingly contagious. The lack of any obvious symptoms during these early stages lends itself to the spread of the disease.
Contact by the virus with the surface cells of the respiratory passages, or sometimes the conjunctiva (the outer surface of the eye), allows the infectious agent to enter the body. The virus spreads through the local lymph nodes into the blood, producing a primary viremia. During this period, the virus replicates both in the lymph nodes and in the respiratory sites through which the virus entered the body. The virus returns to the bloodstream, resulting in a secondary viremia and widespread passage of the virus throughout the body by the fifth to seventh day after the initial exposure.
The initial incubation period is followed by a prodromal stage, in which active symptoms appear. This stage is characterized by a fever that may reach as high as 103 degrees Fahrenheit, coughing, sensitivity of the eyes to light (photophobia), and malaise. Koplik spots appear on the buccal mucosa in the mouth one to two days prior to development of the characteristic measles rash.
The maculopapular rash first appears on the head and behind the ears and gradually spreads over the rest of the body during the course of twenty-four to forty-eight hours. Clear signs of respiratory infection appear, including a cough, pharyngitis, and occasional involvement of the bronchioles or even pneumonia. While malaise and appetite loss are common during the fever period, diarrhea and vomiting generally do not occur. Over time, the rash becomes increasingly dense, exhibiting a blotchy character. Desquamation is common in many affected areas of the skin. Gradually, over a period of three to five days, the rash begins to fade, usually following the sequence by which it first appeared. The rash fades first on the forehead, then on the extremities.
What are the next appropriate steps in management?
Testing:
CDC recommends that either a nasopharyngeal swab, throat swab, or urine specimen as well as a blood specimen be collected from all patients with clinical features compatible with measles. Nasopharyngeal or throat swabs are preferred over urine specimens. Detection of measles RNA is most successful when specimens are collected on the first day of rash through the 3 days following onset of rash. Detection of measles RNA by rRT-PCR may be successful as late as 10-14 days after rash onset.
Isolation and Infection Control:
Since measles is highly contagious, infected individual or suspected exposure and who are symptomatic should adhere to isolation immediately. Since setting is outpatient, patient is to be isolated by staying/quarantine at home to prevent transmission of the virus to healthy individuals. Infected people can spread measles to others from four days before through four days after the rash appears.
Thorough handwashing is highly recommended to prevent cross contamination.
Reporting:
Measles is nationally notifiable, and cases should be reported to the appropriate health department. Measles cases are reported by states to CDC through the National Notifiable Diseases Surveillance System (NNDSS). Surveillance and prompt investigation of cases and contacts help to stop the spread of disease.
Treatment:
The goal of treatment for Measles (Rubeola) is to help decrease the severity of the symptoms. Since it is viral infection, antibiotics are ineffective. Treatment may include:
Increased fluid intake to prevent dehydration.
Acetaminophen for fever. DO NOT GIVE ASPIRIN. The use of aspirin during a viral illness has most commonly been linked to Reye’s syndrome, a potentially life-threatening condition in such children due to worsening of damaged mitochondria causing increased serum ammonia resulting to swelling of their brain (cerebral edema and increased intracranial pressure).
Vitamin A. According to WHO two doses of Vitamin A 200,000 IU are recommended for all children in developing countries who get measles, to help prevent eye damage and blindness and decrease number of deaths from the disease. If the child has clinical signs of vitamin A deficiency (such as Bitot’s spots), a third dose should be given 4–6 weeks later.
Vaccination Education:
Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. CDC recommends routine childhood immunization for MMR vaccine starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or at least 28 days following the first dose. The measles-mumps-rubella-varicella (MMRV) vaccine is also available to children 12 months through 12 years of age; the minimum interval between doses is three months. MMRV should not be administered to anyone older than 12 years of age.
People without previous measles vaccination or infection should receive the MMR vaccine within 72 hours or immunoglobulin (derived from donated blood that contains antibodies to measles) within 6 days of exposure to a patient with measles.
Pls response to Ms. M Discussion Board
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