Fever, wet cough, rash—Dx?

,; ,; ,

Case Reports

Fever, wet cough, rash—Dx?

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

Douglas P. Collins, MD

Sarah Carreira, MD

Christopher R. Bernheisel, MD

PDF Download

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.

THE CASE

An 8-month-old Afghan-American girl was brought to the emergency department (ED) for evaluation of a fever and cough. She had been a full-term newborn and was otherwise healthy and up-to-date on routine immunizations. The patient was alert and crying, but consolable. The patient’s pulse was 140 beats/min, axillary temperature was 100.3°F, and respiratory rate was 25 breaths/min. She had rhinorrhea and scattered rhonchi on lung examination; no abnormal skin findings were reported. A chest x-ray showed nonspecific perihilar streaking without consolidation, which the ED physician interpreted as likely reflecting a viral or reactive airway disease. The patient was diagnosed with possible atypical pneumonia and prescribed a course of oral azithromycin (5 mg/kg/d for 7 days).

Two days later, the baby’s parents brought her to our outpatient office because she still had a fever and had developed a rash that had moved from her face to her trunk to her upper arms. The girl also had a wet cough, rhinorrhea, pharyngitis, emesis, nonbloody diarrhea, and poor fluid intake with low urine output. She was fussy and unable to produce tears while crying.

She had an axillary temperature of 100.5°F and a respiratory rate of 60 breaths/min. She also had mild facial edema, copious nasal discharge, erythematous ear canals with opaque, bulging tympanic membranes, right eye discharge, tachycardia, and tachypnea. The patient had pink to violaceous blanching papules and plaques of varied size and shape on her face, chest, abdomen, back, genitals, and upper arms. The plaques were surrounded by halos. She had no lesions on her oral mucosa, palms, or soles.

The parents indicated that the baby’s fever and accompanying symptoms had started 5 days after she and her mother had returned from a 6-week trip to Kabul, Afghanistan to visit family. They stayed in air-conditioned housing, didn’t travel rurally, and had no known exposure to illness. The patient had taken malaria prophylaxis as prescribed.

Due to the appearance of the patient’s rash and the fact that it had appeared soon after she started an antibiotic, we suspected she had a drug allergy that was complicating an upper respiratory viral syndrome with moderate (7%-10% loss of body weight) dehydration. However, given the history of travel along with the presence of cough, rhinorrhea, diarrhea, and a descending rash beginning on the face, we also considered measles.

We instructed the parents to immediately take their daughter to the regional children’s medical center for intravenous fluids and further evaluation. However, possibly due to miscommunication or cultural barriers, they did not go to the children’s hospital ED.

THE DIAGNOSIS

The next day, the Centers for Disease Control and Prevention (CDC) notified us that there had been a case of measles in a child who had been on the same return flight from Afghanistan as our patient. The CDC also confirmed a recent measles outbreak in Kabul.

The local public health department immediately reached out to the patient’s parents, tested the infant, and quarantined the family. Subsequent serologic and polymerase chain reaction (PCR) testing confirmed measles.

DISCUSSION

The appearance of the patient’s rash soon after she started an antibiotic led us to initially suspect a drug allergy.Measles (English measles/rubeola) is a highly contagious morbillivirus in the paramyxovirus family that spreads quickly through respiratory droplets and remains suspended in nonventilated waiting rooms after an infected patient has left.¹

Measles is a leading cause of vaccine-preventable childhood mortality in the world, accounting for an estimated 46% of 1.7 million deaths in 2000.² Measles disproportionately affects poorer communities, where vaccines may not be available. If just 10% of the population is not immunized, outbreaks can occur.³

Fortunately, thanks to increased immunization, the number of deaths due to measles worldwide has been on the decline, from approximately 733,000 in 2001 to 164,000 in 2008.^3,4 Measles is no longer endemic in the United States and is near elimination in the Western Hemisphere if vaccination coverage remains high.

Vaccination. If not traveling internationally, children should receive measles-mumps-rubella (MMR) vaccination between 12 and 15 months and the second dose should be given before they reach age 4.⁵ However, the CDC reported that in 2014, the number of measles cases in the United States had reached a 20-year high, with 593 cases reported as of August 8.⁶ Many of these cases involved Americans who were not vaccinated before traveling to countries where the disease was prevalent.⁴

Before traveling internationally, infants ages 6 to 11 months should receive one MMR vaccination and children >12 months should receive 2 doses before leaving the United States.⁵