A febrile 11-month-old boy with fever and skin rashes
Prepared by...
Tavitiya Sudjaritrak, M.D.
Virat Sirisanthana , M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
Address: Chiang Mai province.

Referred from a private hospital

Chief compliant: Fever for 5 days.
Present illness:
> 5 days prior to admission he developed gradual onset of high graded fever with cough but no runny nose. His parents took him to a private hospital.
> At private hospital, his temperature was 40?C and the doctor noted that he had mild injected pharynx. So he was diagnosed as URI and received antipyretic drug (paracetamol syrup) and oral antibiotic (cephalexin syrup).
> On the third day of fever he was taken to see a doctor at private hospital again due to persisting of fever and he had diarrhea. Stool exam revealed mucous. He was diagnosed as infectious diarrhea and was given oral antibiotics (norfloxacin).
> 2 days prior to admission he developed exanthematous rash on face especially periocular regions, palms and soles. He still had cough. The doctor suspected of drug allergy, so the oral antibiotics (cephalexin and norfloxacin) were switched to ceftibuten oral suspension (third generation cephalosporin) but fever and exanthematous rash persisted.
> On admission day, he still had high graded fever and the exanthematous rash spread from face to trunk, back and extremities. He also had non purulent conjunctivitis. His parents took him to the same private hospital and the doctor suspected of Steven Johnson Syndrome (SJS) or measles. He was referred to our hospital for admission.
Past history:
> No history of any underlying disease. He received vaccine following Thailand EPI schedule until 6 months of age.
Physical examination:
GA: a febrile boy, irritable, no pallor, no jaundice.
V/S: Body temp (axillary): 39.5 C, PR: 130-150/mins, RR: 32-40/min, BP: 100/60 mmHg.
HEENT: injected conjunctiva both eyes without discharge, no pale conjunctiva, no icteric sclera, mild injected pharynx with enlarged tonsils. There were small white spots (Koplik's spots) on red buccal mucosa in his mouth.
Lymph node:

multiple small non tender cervical lymph nodes were palpable.

Chest: Trachea in midline, no retraction
Lung:

clear, no adventitious sound
Heart:

regular, no abnormal heart sound
Abdomen:

normal contour, active bowel sound, no point of tenderness , liver and spleen can’t be palpable
Skin:

generalized erythematous maculopapular rash on face, entire body and all extremities. Some were confluent (as seen in figure 1 and 2). It started on the face and spread rapidly over the entire body within approximately 24 hr. No petichiae was seen.
 
Figure 1
Figure 2
   
Neurological examination

within normal limit

Problem list:
  1. Fever with generalized exanthematous maculopapular rash and Koplik’s spots
2. Prodromal symptoms: cough, conjunctivitis
3. History of diarrhea
Investigatons:
>
 CBC:
  Hb 11 mg/dL, Hct 33 %, WBC 3,400 cells/cu.mm. (neutroplil 43%, lymphocyte 50%, monocyte 5%, atypical lymphocyte 2%), platelet count 180,000 cells/cu.mm.
>
 Stool examination: no WBC and RBC, no parasite seen.
>

U/A: no rbc, no wbc, pH 6, sp.gr. 1.030, negative for albumin and sugar.

>
 CXR: unremarkable study.
>
 Measles IgM: positive
Diagnosis : Measles
 
Further readings:
English: 1. Link to Parenting and Child Health website: http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=303&id=1857
  2. Slide presentation: Fever with rash prepared by Virat Sirisanthana M.D.
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