A 2-year-old unvaccinated boy presents with a rash about 2 weeks ago after visiting Disneyland with his family. Parents note that he started to have a high fever about 3 days ago with associated cough and runny nose. His eyes also appeared slightly red. Yesterday, he developed a maculopapular rash that started behind his ears before spreading to his face and trunk. This morning, parents also noted the rash appeared to be coalescing and had extended to his arms and legs.
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Correct Answer: Nephrotic syndrome
This boy unfortunately has a measles infection. He is not immunized against measles (he would received his first dose of MMR at age 12-15 mo under a typical CDC immunization schedule) and was exposed from an outbreak at a theme park, which has been seen in recent years
You may recognize the initial prodrome of measles in the stem, which you can remember as the “3 C’s”: cough, coryza, conjunctivitis. This prodrome usually lasts ~3 days and is followed by the classic viral exanthem of erythematous, maculopapular, blanching rash that spreads from face cephalocaudally and centrifugally (head/hairline à down neck to trunk à out to extremities). The exanthem phase may also include lymphadenopathy, fever, and pharyngitis.
- Another key physical exam finding you may be given in a question stem is Koplik spots (whitish spots on erythematous base on buccal mucosa 2-3 days prior to rash)
The special complications of measles to remember include:
- Diarrhea is the most common!
- Neurologic complications of measles can be devastating and occur at different time points.
- Acute encephalitis might occur within about a week of the rash
- Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease that can be seen with various infectious causes such as measles, and would typically present during the recovery phase of measles (within ~2 wks from rash)
- Subacute sclerosing pancephalitis (SSPE) is a rare complication that occurs 7- 10 years after infection with wild-type measles and is characterized by behavioral and intellectual decline and new onset seizures
- Respiratory complications, such as pneumonia (which can be due to measles virus as well as secondary bacterial superinfection), are the most common cause of measles- related death
- Keratoconjunctivitis which can result in blindness
- Others include otitis media, myocarditis, hepatitis. Nephrotic syndrome is not a commonly noted complication of measles
Resources:
- AAP Red Book Section 3: Summaries of Infectious Diseases > Measles
- A review of measles from 2017
- A look at SSPE cases in California from 1998-2015
Written by Sara Dong BIDMC
This question was uploaded on 4/13/22