Pediatrics · Year 3 · from Pediatrics
Case 1: Vaccine-Preventable Disease - Measles
Patient Demographics
- Age: 14-month-old male
- Sex: Male
Chief Complaint
"He has a high fever and a rash all over his body."
History of Present Illness
A 14-month-old unvaccinated boy is brought to the emergency department with a 4-day history of high fever (up to 40.5C), cough, runny nose, and red eyes. Today his parents noticed a red rash starting on his face that has spread to his trunk and arms. He has been increasingly irritable and refusing to eat. He has not received any vaccinations because his parents were concerned about vaccine safety after reading information online. The family recently traveled to an area experiencing a measles outbreak 10 days ago. Several other children in the travel group are now sick with similar symptoms.
Physical Examination
- Vital Signs: Temperature 40.2C, HR 160 bpm, RR 34/min, BP 90/58 mmHg, SpO2 96% on room air
- General: Ill-appearing, irritable toddler
- Eyes: Bilateral conjunctival injection with clear discharge, photophobia
- HEENT:
- Rhinorrhea
- Oral mucosa: White spots with bluish-white centers on erythematous base on buccal mucosa opposite molars (Koplik spots)
- Skin: Erythematous maculopapular rash beginning on face and hairline, spreading cephalocaudally to trunk; some areas becoming confluent
- Respiratory: Cough, lungs with scattered rhonchi
- Lymph nodes: Posterior cervical lymphadenopathy
Laboratory Findings
- Measles IgM antibody: Positive (confirmatory)
- Measles PCR (from throat swab): Positive
- CBC: WBC 4,200/uL (low), lymphopenia
- Chest X-ray: Perihilar infiltrates
Diagnosis
Measles (rubeola)
Clinical Reasoning
This child presents with classic measles: the prodrome of fever, cough, coryza, and conjunctivitis (the "3 C's"), followed by Koplik spots (pathognomonic white spots on buccal mucosa) and then the characteristic maculopapular rash spreading from head downward. The exposure history (travel to outbreak area), 10-day incubation period, and unvaccinated status all support the diagnosis. Measles is highly contagious (R0 12-18), meaning one infected person can infect 12-18 susceptible individuals. This case represents a vaccine-preventable disease in an unvaccinated child.
Management
- Isolation: Airborne precautions; negative pressure room
- Supportive care: Antipyretics, fluids, nutritional support
- Vitamin A supplementation: 200,000 IU orally (reduces mortality and complications)
- Monitor for complications:
- Pneumonia (most common cause of death)
- Otitis media
- Encephalitis (1 in 1,000 cases)
- Subacute sclerosing panencephalitis (rare late complication)
- Public health reporting: Mandatory; contact tracing required
- Post-exposure prophylaxis for contacts:
- MMR vaccine within 72 hours of exposure for eligible contacts
- Immune globulin within 6 days for immunocompromised, infants <12 months, pregnant women
- Education: Discuss importance of vaccination with family
Vaccine Discussion
Why this was preventable:
- MMR vaccine is 93% effective after one dose, 97% after two doses
- First dose recommended at 12-15 months
- This child should have received MMR at 12 months
- Parental concerns were based on debunked misinformation
Clinical Image
Image Description: Koplik spots on the buccal mucosa, appearing as small white spots on an erythematous base, pathognomonic for measles and appearing 1-2 days before the rash.
Source: CDC Public Health Image Library URL: https://phil.cdc.gov/Details.aspx?pid=6111 License: Public Domain