FEVER AND A RASH
History
Euan, a 2-year-old boy, is referred to the paediatric day unit by his GP with a history of fever, cough, blocked runny nose and sticky eyes for 6 days. His GP prescribed amoxicillin 2 days ago for otitis media, and that evening he started to develop a rash around his ears and hairline. His parents stopped giving the antibiotics, but the rash continued to spread over most of his body. The parents report that he has been very miserable and lethargic for the last 5 days. They thought the rash may be an allergic reaction to amoxicillin. He attends nursery but his parents are not aware of any other children there who have been unwell. His parents are well, and he has an older brother who has autism.
Examination
Euan has a temperature of 38.5C, his heart rate is 115 beats/min, respiratory rate 20/min, and oxygen saturation is 97 per cent in air. He weighs 14 kg (75th centile) and he is miserable and lethargic. He has a widespread maculopapular erythematous rash, which is coalescing over his face, neck and torso. Heart sounds are normal, capillary refill time is 2 s. There is no respiratory distress but he is coughing and there are lots of transmitted upper airway noises heard throughout his chest. His abdomen is normal. His nose is streaming with catarrh and he has a purulent discharge from his right ear. His pharynx is red and he has exudative conjunctivitis.
Questions
• What is the most likely diagnosis?
• What essential piece of history has been omitted?
• What complications may arise from this disease and why has its incidence increased recently in the UK?
Medicine
This is a case of measles. The history is typical, commencing with a catarrhal prodrome phase of fever, conjunctivitis, cough and coryza, preceding development of the rash 3–5 days later. During the catarrhal phase, Koplik’s spots may be seen as small white spots on the buccal mucosa. Although pathognomonic of measles, they can be very hard to find and have usually disappeared within 1 day of the rash starting. The rash is maculopapular and starts around the hairline and behind the ears, spreading downwards across the body. It often becomes confluent on the upper body, resulting in a blotchy appearance. Usually children with measles are very miserable.
Differential diagnosis of measles
Clinical distinguishing features
Kawasaki disease Not catarrhal
Rubella Much milder prodrome, occipital lymphadenopathy
Epstein–Barr virus Tonsillitis, lymphadenopathy, not catarrhal
Roseola infantum (human herpes Fever ends as rash appears
virus 6, HHV6)
Scarlet fever Pharyngitis or tonsillitis, not catarrhal
An immunization history is an essential part of any paediatric history and no details have been provided here. In fact, Euan had not received the combined measles, mumps and rubella (MMR) vaccine, which is usually given at 13 months of age.
Complications of measles
• Pneumonia
• Corneal ulceration
• Suppurative otitis media
• Gastroenteritis
• Febrile convulsions
• Encephalomyelitis (rare) and subacute sclerosing panencephalitis (very rare)
Public confidence and uptake of the MMR vaccine fell in the UK following media publicity about a study in 1998 suggesting a link between the vaccine and autism. Despite many publications demonstrating the safety of MMR, and specifically that there is no link to autism, the rate of MMR vaccination in the population fell below that needed to afford herd immunity and cases of measles increased. Measles is a notifiable disease, and prompt notification of suspected cases to the Health Protection Agency allows steps to be taken to minimize further spread and protect those exposed.
KEY POINTS
• Measles has become more common in the UK following a reduction in MMR vaccine uptake.
• Measles has a typical catarrhal phase before onset of the rash.
• The rash evolves in a characteristic fashion, starting around the hairline and behind the ears and spreading downwards.
• Measles is a notifiable disease.
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