Age: 1.26
Sex: F
Vaccine: DTAP, HIBV, MMR, PNC
Symptoms: Body temperature increased, Cough, Decreased appetite, Dehydration, Diarrhoea
Clinical narrative: Information has been received from a health professional concerning a 15 month old female pt with no allergies who on 4/10/03 was at her well child visit when she was vaccinated SC into the right thigh with a first dose of MMR II (644507/1038M). Concomitant therapy included vaccination on 4/30/03 with Prevnar, ActHIB, and diphtheria toxoid (+) pertussis vaccine (+) tetanus toxoid. On 5/8/03 the pt developed a rash and a high fever which lasted for more than 2 weeks. The pt was admitted to a hospital. The physician first thought that it was Kawasaki's disease, but that was ruled out. It was reported that by 5/21/03 the pt had fully recovered. Follow-up info received from a physician indicated that the pt was brought in on 5/8/03 with a history of fever (102-104 degrees F) and rash that started on 5/7/03. On 5/8/03 the temp was 97 deg F. The pt had no loss of appetite, had no occasional cough, nostrils with clear drainage and skin with mild rash. On exam the pt was febrile, no acute distress, good air exchange and both tympanic membranes within normal limits. Her throat was mildly red, RST was negative and she had a fine macular rash all over the face, upper abdomen and neck. It was reported that she had no adenopathy and no other rash. The pt was active and alert. At the time the possible diagnosis was "possible MMR reaction." The plan was for the pt to continue Motrin every 5-8 hours and Tylenol in between and to push fluids and watch fever over the next 2-3 days. The mother was instructed to call with any problems. On 5/12/03 the mother stated that the fever started to go up and down over the last 5 days. On 5/10/03 the pt was spiking a fever up to 105 deg F and had a decreased appetite. The pt had been receiving alternating doses of Motrin and Tylenol. She had a dose of Motrin at 10:30am on 5/12/03, the rash was all over and she had a decreased appetite. It was reported that the pt had some diarrhea in the last four days, which was florescent green and then turned yellowish. The mother had been giving water instead of Pediatlyte since she was unable to get the Pedialyte into the pt. There was no vomiting but the fever kept spiking to 104-105 deg F. On exam the pt had somewhat decreased activity, tongue was slightly dry, all tears were present and she had been urinating. The tympanic membranes were within normal limits and her respiratory rate was 48 without retractions. The physician was unable to hear breath sounds since the baby was crying during the exam. The abdomen was soft and the pt had a macular and papular rash all over the body, which could be blanched. There was some dehydration. The temperature was 99.4 deg F and blood pressure was 86/50. The physician was unsure whether this was Rotavirus, pneumonia or possibly meningococcal infection coinciding with MMR reaction. The plan was to call the ambulance since the vital sings were stable for transportation to the hospital for a sepsis workup with urine culture, CBC with diff, chest x-ray, and possibly for IV antibiotics. The pt would then be transported to the hospital if symptoms persisted. The pt was admitted to the hospital on 5/13/03 as the fever persisted and the rash worsened. It was noted that 13 days prior she received MMR II immunization and 2 days later had a slight rash that improved at that time. There was a question of possible occipital lymph nodes being present. The pt had dry lips and denied any conjunctival erythema at the time. The urinalysis was negative and the pt was being given intravenous fluids. The pt's past medical history included 2 episodes of bronchitis. Her immunizations were up to date and she had normal development. All else was reported as being negative. Family history: she had no siblings and social history: there is no tobacco use in the home. Physical examination showed a well-developed but irritable child who had diffuse, blotchy, red confluent rash over her legs, on her trunk, palms, soles and face. She had shotty anterior cervical and occipital lymph nodes. She had red, dry, cracked lips and a slightly red pharynx. She had tarsal conjunctival injections. Her chest was clear and she had no murmurs. She had no hepatosplenomegaly or perianal rash. She had  swollen extremities, particularly her hands and feet with erythema. Neurologically she was irritable otherwise her neurologic exam was normal. The initial impression was that the pt had Kawasaki syndrome. Her liver functions were normal; amylase and lipase were normal. Her hemoglobin was 10.6 with a white count of 13,200, 295,000 platelets, 55 polys, 8 bands, 31 lymphs, 6 monos and a sed rate of 55. The pt was given 2gms/kg of IV gamma globulin and was started on high dose aspirin for two days as her initial therapy for Kawasaki syndrome. The pt remained afebrile; however, on 5/14/03 she continued to have fever. Her rash, however, evolved into an erythema multiforme minor rash (the lesions began to show some central clearing as  well as slightly raised borders), which the physician believed, was secondary to the vaccination with MMR. The pt had an EKG and an echocardiogram, both of which were normal. A preliminary echocardiogram report showed normal coronary arteries, normal function and normal anatomy. The final report was pending. On 5/14/03 her temp was 38.8 deg C and her rash was slightly better. The rash was much more clearly and erythema multiforme minor rash. It was noted that the pt had a chest x-ray at another facility, which was questionable for pneumonia. A repeat PA and lateral chest film was done on 5/15/03. The results were reviewed with radiology and the preliminary read was no evidence of pneumonia. The final read waspending. The pt's lung exam was completely benign throughout her stay. The pt had no evidence of pneumonia. The pt was discharged home on 5/14/03. Because of her gamma globulin, it was recommended that she receive no immunizations for 10 months due to the IVIG. It was reported that in 10 months to a year it would be worthwhile to check the pt's measles titer since the IVIG was given 2 weeks after the MMR immunization. It was also reported that the pt should have titers of the other immunizations given at that time, particularly if she had received Varivax. The physician believed that the pt probably did not have Kawasaki's, however, the physician did elect to treat her. The pt was discharged on Tylenol 150mg pr prn fever and on one half of a baby aspirin 40mg po every day x 28 days per day for 4-6 weeks. It was reported that the pt should get a repeat echocardiogram on 6/18/03 to re-evaluate for any sequelae of Kawasaki syndrome. If the echocardiogram was negative then the aspirin would be discontinued. The physician believed that the primary diagnosis was erythema multiforme minor probably secondary to her MMR immunization. The pt was discharged with  no dietary or activity restrictions. No consults were obtained. On 5/22/03 the pt was brought into the office as a follow up from her hospitalization and her temp was 97 deg F. It was noted that the pt had 1-2 days of low grade fever after discharge. The physical exam was completely negative, the child was more active and alert and no rash was seen. The pt's head, ears, nose, throat, heart and lungs were all within normal limits. The physician reported that diagnosis was still unsure whether it was "MMR or Kawasaki." It was reported that the pt would be followed up with the echo and would be observed.