A 25 day-old infant with rash

Prepared by......Kraison Pongwilairat M.D..
Discussion by.....Virat Sirisanthana M.D.
Patient: A 25-day-old female infant, Address: Chiang Mai
CC : Fever with rash for 4 days
PI: 4 days prior to admission, the infant developed fever and rash. According to infant's mother the fever and rash occurred on the same day. On the first day the rash appeared as small pink discrete maculopapular rash, which started on the face then spread to the trunk and the extremities at the end of that day. The rash became more prominent and more confluent on the day of admission. Her mother denied any upper respiratory symptom in the infant.
Significant Past History:
> She was born as an uncomplicated vaginal delivery to a 16-year-old mother who had no history of measles vaccination. While the mother was in the hospital for the infant (patient) delivery, she contacted with a case of measles. The infant's birth weight was 2900 grams. She went home with the mother 2 days after the delivery.
> When the infant was 13 days old, her mother developed high grade fever, dried cough, runny nose, and non purulent conjunctivitis. She was seen by a doctor who noticed the Koplik's spots in her oral mucosa. The mother was told that she had measles. Then, the typical (measles)rash occurred and the fever gradually subsided.
Physical examination:
VS: T 39.4 C, Pulse 105/min RR 52/min
GA: an active female infant, not pale, no jaundice, no cyanosis
HEENT: conjunctivitis of both eyes, numerous petechiae at hard palate, pharynx tonsil not injected, no koplik's spots, anterior fontanel 2*2 cm., posterior fontanel 0.5*0.5 cm.
CVS: normal s1 s2, no murmur
Abdomen: soft, liver spleen not palpable
NS: WNL
Skin: erythematous maculopapular rash were seen over the entire body (as seen in figure 1, 2 ). It started on the face and spread rapidly over the entire body within approximately the first 24 hr. Petechiae was also present.
Figure 1
Figure 2
Lab. investigations:
CBC: Hb 14.4g/dl, Hct 43 %, WBC 36,800/mm3 (N 33%, E 6%, L 40%, Atypical lymphocyte 21%, Mo 2%), platelet 33,000/mm3
U/A: no rbc, no wbc 1-2, pH 7, spgr. 1.013, Albumin 1+
ESR: 11 mm/hr
H/C: no growth
Measles IgM: positive,
Measles IgM of infant' s mother: positive
CXR: mild perihilar infiltrations
Problems:
 

> Rash
> Fever
> History of measles in the mother after the delivery
Discussion:
 

> Recently there are increasing number of measles cases inThailand. Most of them occur among measles unvaccinated teenages. The fatal complications, such as pneumonia can occur in unvaccinated, malnourished hill tribe children.

> The history of exposure and the incubation period, along with the typical rash assisted the diagnosis of "measles" in the infant. In this case the diagnosis was made on the second day of rash, the usefulness of immunoglobulin is controversial at this stage.

>It is stated that "Measles in the offspring of mothers with measles ranges from mild to severe. It is therefore recommended that infants born to women with active measles be passively immunized with immunoglobulin at birth". (Ref 1)

> Measles (rubeola) during pregnancy, in contrast to German measles (rubella), is not known to cause congenital anomalies of the fetus. However, measles in pregnancy has been associated with spontaneous abortion and premature delivery. Measles can be severe in pregnancy due to primary measles pneumonia. (Ref 1)

> Maximal dissemination of virus is by droplet spray during the prodromal period (catarrhal stage). Transmission to susceptible contacts often occurs prior to diagnosis of the original case. An infected person becomes contagious by the 9th-10th day after exposure (beginning of prodromal phase). Isolation precautions, especially in hospitals or other institutions, should be maintained from the 7th day after exposure until 5 days after the rash has appeared. (Ref 2)
Course in the hospital:
  Intravenous cloxacillin was started due to leukocytosis and abnormal CXR. The fever subsided in 24 hours. The rash gradully faded away. Other than petechiae, there was no other active bleeding. Platelet count was 55,000/mm3 at the time of the discharge from the hospital.
References and suggested further readings
1. Gershon AA. Measles Virus (Rubeola). In Mandell GL, Bennett JE and Dorin R, eds. Principles and practice of infectious diseases, 5th ed. Philadelphia: Churchill Livingston; 2000:Chapter 149.
2.. Yvonne Maldonado Y. Measles. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia: WB Saunders, 1997: Chapter 206.

Final Diagnosis : A newborn with acquired measles

BACK to Interesting  Case List