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Morning Report

5th Annual Advocacy Project: Immune Wise Section on Medical Students, Residents, and Fellowship Trainees 2009-2010. Morning Report. CC: 12 month old male with rash. CC: 12 month old male with rash. You are in the busy emergency department at the community hospital…

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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. CC: 12 month old male with rash

  4. CC: 12 month old male with rash You are in the busy emergency department at the community hospital… What questions do you want to start with?

  5. CC: 12 month old male with rash • 12 month old awoke with small spots on his face (right side > left) and fainter spots on his stomach and back • He went to his pediatrician this morning for evaluation • The rash worsened/spread this afternoon/evening to include genitals, legs, palms of his hands – more confluent and itchy

  6. CC: 12 month old male with rash ROS: • Decreased PO intake today (UOP x 3) • Tactile fever • Rhinorrhea this evening • No vomiting or diarrhea • No blisters or vesicles • No ingestions/medications

  7. CC: 12 month old male with rash • General: Happy infant with diffuse rash • T 36.8 HR 120 RR 30 Pain 0/10 • HEENT: NC/AT, EOMI, no conjunctival injection, no oral lesions or erythema • Neck: Supple, no LAD • Chest: Lungs CTA, HRRR • Abd: Normal bowel sounds, soft, NT, no HSM

  8. CC: 12 month old male with rash

  9. Differential Diagnosis - Discussion

  10. Management

  11. Erythema Multiforme Minor • Self-limiting • Acute onset of acral and symmetrical erythematous papules evolving into target lesions • Relative absence of constitutional symptoms • Most commonly caused by infections, especially by HSV and Mycoplasma pneumoniae

  12. MMR Vaccine Reactions • Pain, redness, swelling at the site • Fever in 5-15%, with an onset within the 6-12 days following injection • Non-specific rash in 5%, particularly within the second week following vaccination (more common with MMRV than MMR) • One case report from Bernardini et al. Erythema multiforme following live attenuated trivalent measles-mumps-rubella vaccine • Finnish studies show EM minor from MMR to be common • Thrombocytopenia associated with measles component • Arthritis/Arthralgias associated with rubella component

  13. Vaccine Adverse Events Reporting System (VAERS) • Cooperative program of the CDC and FDA started in 1990 • Post-marketing safety surveillance program • Passive reporting system • Collects information about adverse events that occur after the administration of US licensed vaccines • Can identify safety signal but cannot determine causation

  14. Vaccine Adverse Events Reporting System (VAERS) • Who reports? • Health care professionals, manufacturers, parents, state immunization programs • What to report? • Any event after a vaccine concerning to the reporter – fever, rash, seizure, fainting, etc. • A reporter does not have to be certain the vaccine caused the event • Why report? • To improve vaccine safety and strengthen public trust in the FDA and CDC • How to report? • http://vaers.hhs.gov/ • 1-800-822-7967

  15. Reporting Adverse Reactions

  16. Vaccine Adverse Events Reporting System (VAERS) • National Childhood Vaccine Injury Act requires physicians to report two events to VAERS • Any event listed by the manufacturer as a contraindication to subsequent vaccine dosages 2. Any event listed in the Reportable Events Table that occurs within the specified time period after the vaccination

  17. Exam Questions about Vaccine Reactions

  18. Vaccine ReactionsCME questions from Pediatric Emergency Care • Which of the following vaccines is most strongly associated with hypotonic-hyporesponsive episodes? A. MMR B. DTaP C. IPV D. Pneumococcal conjugate E. Hib

  19. Vaccine ReactionsCME questions from Pediatric Emergency Care • Which of the following vaccines is most strongly associated with hypotonic-hyporesponsive episodes? A. MMR B. DTaP – episodes occur within the first 48 hours; lasts 1 minute to 48 hours C. IPV D. Pneumococcal conjugate E. Hib

  20. Vaccine ReactionsCME questions from Pediatric Emergency Care • Which of the following vaccines has a known association with protracted inconsolable crying? A. Hep B B. IPV C. MMR D. DTaP E. Pneumococcal conjugate

  21. Vaccine ReactionsCME questions from Pediatric Emergency Care • Which of the following vaccines has a known association with protracted inconsolable crying? A. Hep B B. IPV C. MMR D. DTaP – events lasting > 3 hours and occurring within 48 hours of injection E. Pneumococcal conjugate

  22. Vaccine ReactionsCME questions from Pediatric Emergency Care • Which of the following vaccines is most likely to be implicated as causing thrombocytopenia? A. IPV B. MMR C. Hib D. Pneumococcal conjugate E. Hep B

  23. Vaccine ReactionsCME questions from Pediatric Emergency Care • Which of the following vaccines is most likely to be implicated as causing thrombocytopenia? A. IPV B. MMR – 1 in 30,000 doses (0.003%), usually 2-3 weeks post vaccine C. Hib D. Pneumococcal conjugate E. Hep B

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