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Morning Report

5th Annual Advocacy Project: Immune Wise Section on Medical Students, Residents, and Fellowship Trainees 2009-2010. Morning Report. Case Presentation. 4 year old female is on the illness clinic schedule Her mom reports 2 days of fever and decreased energy level. Case Presentation.

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Morning Report

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  1. 5th Annual Advocacy Project: ImmuneWiseSection on Medical Students, Residents, and Fellowship Trainees2009-2010

  2. Morning Report

  3. Case Presentation • 4 year old female is on the illness clinic schedule • Her mom reports 2 days of fever and decreased energy level

  4. Case Presentation • Review of Systems • Temp to 102°F • Mild headache • Eye redness • Mild congestion • Non-productive cough • No GI complaints • No rash • PMHx • Healthy • Due for 4-5 year old immunizations • SHx • Lives with parents • No known sick contacts • Recent travel to Disney World (about 10 days ago)

  5. Case Presentation - Exam • General: Cooperative, NAD but appears ill • HEENT: PERRL, bilateral conjunctival erythema and watery eyes, nares patent, MMM without lesions, neck supple, no lymphadenopathy • Chest: CTA bilaterally, no wheeze/rales/rhonchi; HRRR, no murmur/rub/gallop • Abd: Active BS, soft, non-tender, no HSM • Skin: No rash or lesions noted

  6. Case Presentation Diagnosed with a viral upper respiratory infection Supportive care was discussed with the patient’s mother

  7. Case Presentation • The 4 year old returns the next day with a new rash… • Exam is unchanged except for a blotchy, blanching erythematous maculopapular rash on her face and neck

  8. Differential Diagnosis - Discussion

  9. Management

  10. MeaslesEpidemiology • Humans are the only natural host • Transmitted by direct contact with droplets • may contract from airborne droplets too • Most common in preschool and early school-aged children with a late winter peak • Vaccine licensed in 1963 • Vaccine failure rate of 5% in those with only a single dose

  11. MeaslesEpidemiology

  12. Measles Epidemiology

  13. Measles Clinical Presentation • Incubation period of 8-12 days • Symptoms and signs include: • Fever, malaise, cough • Conjunctivitis, coryza, +/- photophobia • Koplik spots on soft palate (often occur before the rash and are diagnostic) • Rash, usually day 2-3 of illness • Contagious for 1-2 days before onset of symptoms until ~4 days after rash appears

  14. Measles Clinical Presentation

  15. Measles Diagnosis • Serum sample positive for measles IgM antibody on initial presentation • Sensitivity varies - low in first 72 hours of rash • If the initial test is negative, consider repeating after the rash is present > 72 hours • Significant rise in measles IgG in paired acute – convalescent samples • Measles RNA in blood, throat, nasopharyngeal or urine samples (by PCR)

  16. MeaslesComplications • Complications include: • Otitis media • Croup or bronchopneumonia • Diarrhea • Severe complications: • Acute encephalitis in 1/1000 cases • Death in 1-3/1000 cases • Usually due to respiratory or neuro complications • Subacute sclerosing panencephalitis (SSPE) • Degenerative CNS disease

  17. Measles Treatment • Supportive care • Vitamin A • Give if vitamin A deficiency is endemic • Give in the U.S under certain conditions Consult Red Book • Ribavirin • Not FDA approved, but may help those severely affected and immunocompromised

  18. Measles Infection Control • Vaccine given within 72 hrs of exposure my provide protection in susceptible individuals • Immune globulin given within 6 days of exposure may prevent or modify measles

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