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High Fever and Red Eyes

4/10/2016

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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
 
​​

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​
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