Fever, wet cough, rash—Dx?

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Case Reports

Fever, wet cough, rash—Dx?

J Fam Pract. 2014 September;63(9):520-523

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References

1. Centers for Disease Control and Prevention (CDC). Update: global measles control and mortality reduction—worldwide, 1991-2001. MMWR Morb Mortal Wkly Rep. 2003;52:471-475.

2. Moss WJ, Griffin DE. Measles. Lancet. 2012;379:153-164.

3. Centers for Disease Control and Prevention. Measles. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf. Accessed July 24, 2014.

4. Mackell SM. Vaccine recommendations for infants & children. Centers for Disease Control and Prevention Website. Available at: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-7-international-travel-infants-children/vaccine-recommendations-for-infants-and-children. Accessed August 8, 2014.

5. Centers for Disease Control and Prevention. Measles cases and outbreaks. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/measles/cases-outbreaks.html. Accessed August 11, 2014.

6. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. Philadelphia, PA: Mosby; 2009.

7. Moss WJ. Measles. Magill AJ, Ryan ET, Solomon T, et al. Hunter’s Tropical Medicine and Emerging Infectious Disease. 9th ed. Philadelphia, PA: Saunders Elsevier Inc; 2012.

8. McKinnon HD, Howard T. Evaluating the febrile patient with a rash. [published correction appears in American Academy of Family Physicians Web site. Available at: http://www.aafp.org/afp/2000/0815/p804.html]. Am Fam Physician. 2000;62:804-816.

9. Wilson ME. Fever in returned travelers. Centers for Disease Control and Prevention Web site. Available at: http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-5-post-travel-evaluation/fever-in-returned-travelers.htm. Updated August 1, 2013. Accessed July 24, 2014.

10. Lopez FA, Sanders CV. Fever and rash in the immunocompetent patient. UpToDate Web site. Available at: http://www.uptodate. com/contents/fever-and-rash-in-the-immunocompetent-patient. Updated June 23, 2014. Accessed July 24, 2014.

11. Feder HM Jr, Mansilla-River K. Fever in returning travelers: a case-based approach. Am Fam Physician. 2013;88:524-530.

12. Centers for Disease Control and Prevention (CDC). Malaria deaths following inappropriate malaria chemoprophylaxis— United States, 2001. MMWR Morb Mortal Wkly Rep. 2001;50: 597-599.

13. Centers for Disease Control and Prevention. MMWR: Summary of notifiable diseases. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/mmwr/mmwr_ nd/index.html. Accessed July 24, 2014.

14. Lo Re V 3rd, Gluckman SJ. Fever in the returned traveler. Am Fam Physician. 2003;68:1343-1350.

15. Huiming Y, Chaomin W, Meng M. Vitamin A for treating measles in children. Cochrane Database Syst Rev. 2005;(4):CD001479.

16. World Health Organization. WHO guidelines for epidemic preparedness and response to measles outbreaks. World Health Organization Web site. Available at: http://www.who.int/csr/ resources/publications/measles/whocdscsrisr991.pdf. Accessed July 24, 2014.

17. Fiebelkorn AP, Goodson JL. Infectious diseases related to travel. Centers for Disease Control and Prevention Web site. Available at: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/measles-rubeola. Accessed August 19, 2014.

Look for fever, rash, and “the 3 Cs”

During its incubation period, the measles virus replicates in the epithelial cells and spreads first to the local lymphatics and then hematogenously to multiple organs.⁴A fever typically develops 10 days after exposure; the rash develops about 4 days later.⁴

The measles rash is maculopapular and starts on the face, progresses to the trunk and then limbs, and coalesces (FIGURE). The rash typically lasts 3 to 5 days and clears in the same distribution that it appeared.³ The rash is part of a classic clinical presentation that also includes the “3 Cs” (cough, coryza [rhinorrhea], and conjunctivitis). In addition, patients may develop diarrhea and/or Koplik spots, an enanthem of small blue-white haloed lesions on the buccal mucosa (not palate) that are an early manifestation of illness.

Complications occur in around 40% of patients.⁷ Pneumonia is most common; other complications include croup and otitis media. Stomatitis may hinder children from eating. Rare but serious complications include late central nervous system manifestations such as encephalomyelitis, which affects 1/1000 people with measles.⁷ Measles inclusion body encephalitis and subacute sclerosing panencephalitis may emerge months to years after the acute infection and can cause progressive cognitive deterioration and death.⁷

Timing of fever  helps narrow the diagnosis

The differential diagnosis for fever and rash in a returning traveler is broad (TABLE 1)^8-10 and can be narrowed by a thorough history and exam (TABLE 2).^10,11 Reportable public health conditions must be considered in all returning travelers who present with fever, particularly malaria, due to the possibility of acute deterioration.^12,13 The timing of fever in relation to travel helps narrow the differential diagnosis. If the incubation period is <21 days, many viral infections (including measles, dengue fever, and chikungunya), malaria (especially falciparum), typhoid fever, leptospirosis, and rickettsial diseases should receive top consideration. If the period is >21 days, other causes are more likely.¹⁴

TABLE 2
Taking a returning traveler's history: What to ask^10,11

Personal history

Age
Environmental and animal exposures
Sick contacts
Medications
Childhood illnesses
Immunization status
Immune status

Travel history

Purpose of travel
Geographic location/areas/altitude visited
Season of year in region traveled
Activities/exposures (food, freshwater, sexual contacts)
Accommodations
Adherence to prophylaxis
Pretravel immunizations

The diagnosis of measles can be confirmed by serologic testing for measles-specific immunoglobulin M (IgM) antibodies (which may not be detected until 4 or more days after the onset of rash) or a 4-fold rise in immunoglobulin G. Detection of measles ribonucleic acid by PCR assay also can provide confirmation.³

Vitamin A can lower risk  of mortality, blindness

Treatment of measles consists of supportive care and administration of vitamin A—regardless of the patient’s nutritional status. Vitamin A reduces mortality, decreases the risk of corneal damage, and promotes more rapid recovery and shortened hospital stays.^1,15 World Health Organization guidelines recommend administering specific dosages of vitamin A on 2 consecutive days based on the patient’s age (TABLE 3).¹⁶ For patients with an underlying vitamin A deficiency, a third dose 2 to 4 weeks later is recommended.¹⁷

Our patient

We prescribed vitamin A for our patient but did not administer it. The patient did not follow up and we were not able to confirm the outcome.

THE TAKEAWAY

Vitamin A can lower mortality, decrease the risk of corneal damage, and promote rapid recovery in patients with measles.Before patients travel, counsel them on the need for appropriate immunizations. The MMR vaccine should be given to any child older than age 6 months who will be traveling to a high-risk setting. Health-related information for people who plan to travel is available from the CDC at http://wwwnc.cdc.gov/travel and the US Department of State at http://travel.state.gov/content/passports/english/country.html.

To evaluate fever and rash in an individual returning from travel, take a thorough personal and travel history. Suspect measles in patients who present with cough, rhinorrhea, conjunctivitis, diarrhea, and a descending rash that began on the face. The diagnosis can be confirmed with serologic or PCR testing. Treatment should include supportive measures and vitamin A, regardless of the patient’s nutritional status.