High Fever and Red Eyes

Case Presentation: You are working in a Palestinian refugee clinic in Lebanon where a 3-year-old male presents to your clinic for high fevers for 1 day. The patient’s mother also states that the child has had a cough, runny nose, and red eyes. The patient and his family recently relocated to Lebanon from Aleppo, Syria.
 
ROS: Otherwise negative
PMH: Previously healthy
PSH: Negative
FH: Non-contributory
Immunization History: Unable to seek regular primary care for the past 2 years secondary to conflict in Syria
Allergies: None 


Physical Exam:
Vital Signs: Temp = 39 C, HR = 150, BP = 90/50, RR = 34, O2 Sat = 96% RA
General: Warm to the touch, appears tired, lethargic, cries during exam, but comforted by mother
Skin: Cheeks are erythematous, no rash appreciated
HEENT: Bilateral conjunctivitis, dry oral mucosa appreciated with blue-gray macules with erythematous base on buccal and gingival mucosa
Neck: Spotty cervical lymphadenopathy, no meningeal signs
Lungs: Course breath sounds bilaterally with upper airway noises
CV: Tachycardia
Abd: Soft, non-tender, non-distended
Ext: No acute findings
Neuro: Appears sleepy, but arousable and consolable by mother 

Differential Diagnosis

• Viral illness = adneovirus, influenza, varicella, roseola, parvovirus B19, eterovirus
• Group A strep infections (scarlet fever/toxic shock)
• Drug eruption 
• Pharyngitis
• Pneumonia
• Bronchiolitis
• Measles
• Meningococcemia
• RMSF
• Mono
• HSP
• Kawasaki disease
• Dengue fever 
• Sepsis

Work-Up

• CBC = WBC 3.9 Hg 11.2 Hct 34 Plt 453
• CXR = WNL
• URINE = negative 

Diagnosis = MEASLES
Measles

• Measles is one of the leading causes of death among young children
• Per the World Health Organization:
  • In 2014, there were 114,900 measles deaths globally
  • 314 deaths every day or 13 deaths every hour.
• Highly contagious; 90% secondary infection

 
Etiology

• Single-stranded, negative-sense enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae.
• Transmitted by close contact with infected person who is coughing/sneezing or by direct contact with their secretions
• Who gets infected: HIV/AIDS, leukemia, chronic steroid usage, or immunocompromised states, travel to regions where measles is endemic, infants without passive immunity prior to immunization, unimmunized
• Pregnancy, malnutrition, Vitamin A deficiency, and immunocompromised state can predispose a person to severe complications

 
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Pathophysiology

• Most cases present in late winter/early spring
• Transmitted in respiratory secretions
• Can lead to immunosuppression of IL-2 production and antigen specific lymphoproliferative response = secondary infections
• Incubation period from exposure to onset of measles symptoms ranges from 7 to 14 days; contagious from 1-2 days before the onset of symptoms

 
History

• Associated with high fever, malaise, decreased appetite
• Classic triad of “3 Cs”: cough, coryza, conjunctivitis
• Rash starts on face and neck and spreads downwards over trunk and extremities; typically lasts 3-5 days
• In otherwise healthy children, total course of illness lasts about 7-10 days

 
Physical Exam

• Koplik spots: pathognomonic for measles, white lesions on buccal mucosa opposite second molar
• Rash = blanching, erythematous macules/papules starting at face/neck then coalesce and then spreads cephalocaudally to trunk and extremities
• Rash typically lasts about 5-7 days and can desquamate 

Complications

• Due to measles virus suppressing host’s immune system
• Reactivation of latent infection vs superinfection
• More likely to occur if < 5/> 20, immunocompromised, Vitamin A deficient, or malnourished
• Common complications: bacterial pneumonia, otitis media, croup, encephalomyelitis, diarrhea, lymphadenitis, keratitis, subclinical hepatitis
• Less common complications: DIC, subacute sclerosing panencephalitis, pericarditis/myocarditis, purpura fulminans, acute pancreatitis

 
Treatment

• Mainly through supportive care
• Must be reported to health department
• Ensure adequate hydration (use ORS)
• Vitamin A supplementation: reduce the number of deaths from measles by 50% and can help prevent eye damage and blindness
  • Dosing as follows:
    • Less than 6 months:  50,000 IU/day PO for 2 doses
    • 6-11 months: 100,000 IU/day PO for 2 doses
    • 12 mo or greater:  200,000 IU/day PO for 2 doses
    • Signs of vitamin A deficiency – Give 2 doses as appropriate for age followed by a third age-specific dose given 2-4 weeks later

• Routine vaccinations for prevention
• Treat bacterial complications
• Per AAP Guidelines released in 2015:
  • Immune globulin either IM/IV within 6 days of exposure to prevent or modify measles response in people who lack evidence of measles immunity (including infants 6 months – 1 year, pregnant women, immunocompromised patients, and infants < 6 mo born to mothers without immunity)
  • - 0.5 mL/kg administered intramuscularly, with a maximum volume of 15 mL
  • Groups who are at higher risk for complications from severe measles should receive IV dose at a dose of 400 mg/kg

Vaccinations

• Vaccination recommendations per CDC:
  • For children: two doses of MMR vaccine, 1st dose at 12 through 15 months of age, 2nd dose at 4 through 6 years of age
  • Ok to give 2nd dose earlier as long as it is at least 28 days after the first dose
  • Adults without evidence of immunity should get at least one dose of MMR vaccine
• International travel vaccination recommendations per CDC:
  • Infants 6 through 11 months of age: receive one dose of MMR vaccine.
    • Infants who get one dose of MMR vaccine before their first birthday should get two more doses
  • Children 12 mo and older: receive two doses of MMR vaccine, separated by at least 28 days.
  • Teenagers/adults without immunity to measles: receive two doses of MMR vaccine separated by at least 28 days
• Who should NOT be vaccinated per CDC:
  • Anyone with a life-threatening allergic reaction to a previous dose of MMR vaccine/gelatin/neomycin
  • Anyone with HIV/AIDS with severe immunocompromised state, with leukemia, or with any other disease that effects immune system
  • Anyone being treated with immunosuppressing drugs including high dose oral steroids, radiation, or chemotherapy

For more information:
http://www.who.int/immunization/diseases/measles/en/
http://refbooks.msf.org/msf_docs/en/measles/measles_en.pdf​