Age: 1.6
Sex: F
Vaccine: HEPA, IPV, MMR, HEPA, IPV, MMR
Symptoms: Pyrexia, Rash generalised, Rash morbilliform, Rash papular, Red blood cell sedimentation rate normal
Clinical narrative: Information has been received from a physician concerning a 19.5 month old female with Ear infection who on 20-MAY-2009 was vaccinated with MMR II. Concomitant therapy included AMOXICILLIN. On 28-MAY-2009 the patient went to the emergency room because the patient had a measles like rash all her body and had a 104 degree fever. The patient was admitted to the hospital. The physician reported that the patient was in the hospital for two days and since has recovered. Lab diagnostics include test for IGT antibodies IGM. Follow up information was received from the physician via medical record which reported that on 20-MAY-2009 the patient was vaccinated with a dose of MMR II, a dose of POLIO (unspecified) and a dose of HEP A (unspecified). The patient did have an otitis media diagnosed about the time she received the vaccines and she was started on AMOXICILLIN, which she completed a weeks worth on 27-MAY-2009. Three days prior to admission, on 28-MAY-2009 the patient began with vomiting. There was no blood associated in the emesis. She vomited once that day and once the next day. She developed a fever to 104.6 F the day after her symptoms began. She had mild running nose and cough. She also developed a rash, which began in her stomach and thighs and since had spread to encompass nearly the whole body with some areas that had become confluent. The mother had been giving her TYLENOL and MOTRIN, which had been helpful with the fever, but she had continued to have high fevers at home periodically. The mother reported that she had had some mild congestion, but no significant coughing. She had not had any redness to her eyes. She had been fussy at times, particularly with the fever, but generally her mood had been actually quite good. She had been eating. She had not had any problems with diarrhea or vomiting after 29-MAY-2009. She did not seem to be itching the rash at all either. Due to the significant rash, the mother brought her into the emergency room where she was febrile to 39.3 C and there was concern for the possibility of measles, so she was admitted for further evaluation and management in the early morning of 01-JUN-2009. review of systems was negative, physical examination was within normal limit except that her nose with some clear discharge, her throat was mildly red. Tonsils were 2-, her neck had minimal lymphadenopathy in the cervical chain. The rash on the skin was widespread pink papules, which came to confluence on her upper arms and her face. Laboratory test were performed included a complete blood count, which was unremarkable with particularly a normal white cell count and normal platelet count with a differential of 50 segments, 36 lymphocytes, 4 monocytes. comprehensive metabolic panel had a glucose of 120, revealed a normal ALT, AST with an elevated albumin, was otherwise unremarkable. Urinalysis specimen gravity 1.025, Ph 6.0 and only 1 white blood cell per high power field. She had small hemoglobin. Microscopic was fairly unremarkable. She did have a blood culture pending. since the patient with a severe rash what looked like a viral illness and she was recently on AMOXICILLIN to treat her ear infection and her mother reported that she had not had ear infections in the past, the assessment included highly suspicious for measles and possibility of a drug-induced eruption. The patient was referred to the other physician with pediatric infectious disease late in the morning of 01-JUN-2009. Laboratory results returned and indicated that ESR, 10 and CRP was 2.4. Blood culture was no growth to date. The physician's assess was the patient's fever and rash were potentially consistent with an MMR II adverse reaction, but the physician was not convinced that this was measles MMR II. Other possibility included viral infections including HHV 6, CMV, EBV, parvovirus, non-infectious etiologies to consider include Kawasaki's disease and Stevens-Johnson syndrome. But it seemed that patient that the patient did not meet the criteria for atypical Kawasaki's disease at this point as she had only had 4 days of fever. Her sedimentation rate and CRP were also low to merit further workup. Her albumin and white cell count and hemoglobin and platelet count as well as her AST and ALT and urinalysis did not meet criteria for Kawasaki's disease workup. The physician also recommend to check for other viral infections by dong a DFA as well as EBV PCR, mycoplasma PCR, HSV PCR, looking for common infectious causes of Stevens-Johnson syndrome, also checking blood cultures. Echocardiography was not recommended to be performed. The results for HSV, EBV, CMC, viral DFA and HHV 6 were negative with the exception of a positive rhinovirus. On 02-JUN-2009 the patient was discharged with the diagnosis of probable viral exanthema and possible immunization reaction. The patient's rash had improved significantly over about 36 hours while being watched in the hospital, although it was still present. The patient was afebrile for over 24 hours at the time of discharge and felt to be safe to go home. He measles IgM and IgG titers were pending at the time of discharge. The patient was scheduled to be seen 2 days after discharge. The mother was recommended to contact the physician if the patient's fever persisted after discharge. The result for measles was reviewed and indicated IgM was negative and IgG was equivocal. At the time of reporting, the patient recovered from the events. Additional information is not expected. Available medical records will provided upon request.