With the contagious culprit ruled out , what was the real cause of this infant ’ s rash ?
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Mimicking measles
THE AUTHORS
Dr Peter Chisholm is a medical registrar .
Dr Alisara Suknate is a medical registrar .
Dr Lyn-li Lim is an infectious diseases physician .
Dr Alice Fang is a paediatrician and neonatologist .
All work at Eastern Health , Melbourne .
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PAEDIATRICS
With the contagious culprit ruled out , what was the real cause of this infant ’ s rash ?
SAM , aged 12 months , was brought into the ED by his parents with a two-day history of rash , associated with a five-day history of fever , coryzal symptoms and decreased food intake .
There was no associated cough . Two days before the onset of the fever , Sam had received his 12-month MMR , haemophilus influenzae type b and meningococcal C vaccinations . 1
He had last attended childcare two weeks before presentation . There was no significant history of travel or infectious contacts . His past medical history was unremarkable ; he was born at term and was meeting developmental milestones .
On examination , Sam was alert but irritable . He had a fever of 38.9 ° C , but his other vital signs were within normal range .
Initial examination revealed a maculopapular rash , largely involving the legs and buttocks and extending to the abdomen , trunk and back ( see figure 1 ). He had palpable cervical lymphadenopathy ( ≤1cm nodes ), with no signs of otitis media or Koplik ’ s spots .
Management Sam was admitted to hospital for exclusion of measles and observation . Investigations revealed a neutrophilia at 12.14 x 10 9 L ( normal 1.25-7.50 x 10 9 L ), a mild lymphopenia at 2.84 x 109L ( normal 4.75-10.00 x 10 9 L ) and an elevated CRP of 158mg / L ( normal is less than 5mg / L ). Nose and throat swabs for measles RNA were negative .
The following day , further questioning revealed Sam had had bilateral non-purulent conjunctivitis since the onset of the fever . Additional examination confirmed the previous assessment findings and the bilateral non-purulent conjunctivitis , with an erythematous oropharynx .
Diagnosis Sam was diagnosed with Kawasaki disease and was treated with IV immunoglobulin ( IVIg ) and aspirin . The rash , fever and lymphadenopathy resolved within three days of IVIg administration . After discharge , close outpatient follow-up for cardiovascular complications was arranged .
Discussion Fever and maculopapular rash in an unwell and non-immune child should raise suspicion of measles . Measles is classically characterised by cough , conjunctivitis and a maculopapular rash involving the face and neck and extending downwards . Measles is an acute viral illness spread by airborne droplets , aerosol and direct contact and is highly infectious via the respiratory route . 3
Measles infection contracted prior to vaccination was a possible cause of Sam ’ s presentation , given the typical incubation period is 7-18 days . 4
However , a facial-sparing rash and the absence of cough would be unusual for measles . Importantly , there were no reported cases in the community at that time , and swabs for measles RNA were negative .
Measles vaccine reaction , which typically presents 7-10 days post-vaccination , with malaise and / or rash that is non-infectious , was also considered in this infant . 1
While most viral exanthema in infants seen in daily practice are self-limiting and do not require
further investigation or treatment , paediatric or ED referral should be initiated if the fever fails to improve at seven days without explanation or at five days if at least one additional criterion of Kawasaki disease is present . When patients present to general practices or EDs with suspected measles , infection control measures should be initiated as soon as practicable . This includes droplet and contact precautions , including separating the index patient from other patients in the waiting room .
For patients who are referred to an ED , it is important to forewarn the department to prepare to divert the patient to a negative – pressure room rather than waiting in the triage area . 4
Measles is investigated by collecting nose and throat PCR swabs for measles RNA . Sensitivity is highest 1-3 days after rash onset , but the virus can be detected up to 10-14 days later . 5 Measlesspecific IgM and IgG antibodies are not useful in
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