Age: 41.0
Sex: M
Vaccine: MMR
Symptoms: Nasal congestion, Oropharyngeal pain, Pancytopenia, Paraesthesia, Protein total normal
Clinical narrative: This literature marketed report as received from a physician refers to a 41 year old male patient. The patient was admitted to this hospital in midsummer because of fever, rash, pancytopenia, and abnormal results of liver function tests. The patient had been well until 6 days before admission, when fever with a peak temperature of 38.2 C, fatigue, headache, and mild sore throat developed. Two days after the onset of fever, he came to the medical walk-in clinic at this hospital because of persistent symptoms. He also had atopic dermatitis, which had been treated intermittently with topical glucocorticoids. He had taken aspirin and acetaminophen for the fever, with transient improvement. The patient had no known allergies. He was born in another country and had moved 6 months earlier. He worked in an office and traveled frequently. Two days before the onset of fever, he had returned from a 3-week trip to a foreign country, during which he had gone mountain biking and hiking. He had not noted any insect bites. He drank alcohol infrequently, did not smoke or use illicit drug, and reported sexual activity only with his wife, who was pregnant. On examination, the vitals signs were normal. There were tender lymph nodes in the anterior cervical region; the largest was on the right side and measured 1 cm in diameter. A rapid antigen-detection test for streptococcal pharyngitis was negative, and a throat specimen was obtained for culture. A presumptive diagnosis of viral pharyngitis was made. Two days later, the patient returned to the clinic because of fever with a peak temperature of 39.4 C, fatigue, malaise, arthralgias, diaphoresis, and mild headache; he did not have neck stiffness, photophobia, cough, or gastrointestinal symptoms, and his sore throat had resolved. On examination, he appeared mildly ill. The temperature was 38.9 C, the blood pressure 117/79 mm Hg, and the pulse 102 beats per minute. The conjunctivae were pale and anicteric, and he had mild nasal congestion, a mobile left axillary lymph node (1 cm in diameter) that was not tender, and bilateral anterior cervical lymphadenopathy with supple, small lymph nodes. There were multiple pigmented macules on his trunk that reportedly had been present for decades. The throat culture taken 2 days earlier was negative for group A streptococcus. Blood levels of glucose, total protein, albumin, globulin, calcium, and total bilirubin were normal, as were results of renal function tests. Urinalysis revealed clear yellow urine, with 2+ albumin, 1+ blood, and 0 to 2 white cells and red cells per high-power field. After blood cultures were obtained and the administration of doxycycline was begun, the patient returned home. The next evening (5 days after the onset of symptoms), he came to the emergency department at this hospital because of fever with a peak temperature of 40 C and a new rash on his torso that had appeared after the third dose of doxycycline. He reported decreased appetite and had stopped taking ibuprofen and acetaminophen because of gastrointestinal discomfort. He reported having received all recommended childhoods vaccinations. The temperatures was 38.9 C, the blood pressure 136/83 mm Hg, the pulse 95 beats per minute, the respiratory rate 16 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. Bilateral anterior cervical lymphadenopathy was present, as were multiple faint, non-pruritic macules on his upper chest, abdomen, and back. The remainder of the examination was unchanged. Blood levels of total and direct bilirubin, phosphorus, and magnesium were normal. The administration of doxycycline was stopped, levofloxacin was begun, and acetaminophen was continued. Overnight, during a febrile episode, the patient's oxygen saturation decreased to 93% while he was breathing ambient air; supplemental oxygen was administered. The next day, the temperature rose to 39.7 C. Levofloxacin was discontinued because of the persistent fever, and the administration of ceftriaxone and azithromycin was initiated. Albuterol was given by nebulizer, and the acetaminophen was alternated with ibuprofen. After 25 hours in the observation until (6 days after the onset of symptoms), the patient was admitted to this hospital. On examination, the temperature was 38.3 C; other vital signs and the oxygen saturation were normal. There was a faint, small maculopapular rash on the chest, abdomen, and back; the remainder of the examination was unchanged. Blood cultures obtained 2days earlier remained without growth. Red papules developed on the patient's forehead and face on the second hospital day and later spread to his arms; the rash was associated with a prickly sensation. The maximum temperature was 38.3 C. Results of coagulation tests were normal. A repeat chest radiograph showed that the patchy left basilar opacity had decreased in size from the previous study. The patient received prophylaxis with enoxaparin. The administration of doxycycline was restarted, azithromycin was stopped, and fexofenadine was begun. During the next 2 days, the patient's fever resolved and he felt better. On examination, a few petechiae were noted in the oropharynx. There was a diffuse rash with monomorphic, smooth, nonscaly, dome-shaped, reddish-pink papules (1 to 3 mm in diameter) on the face, trunk, arms, legs, hands, and feet but not on the palms or soles. The classic morbilliform rash described in this case was so named because of its association with measles. This patient presented with many of the features of measles and could have been exposed to the disease during his travels; however, he reported that he had received all his childhood vaccinations with living in a foreign country. He was born in the mid-1970's, and thus it is likely that he received at least one dose of a monovalent live-measles vaccine; however, measles immunity was often incomplete after a single dose, especially if that dose was administered at less than 12 months of age. It was not known whether this patient received a booster dose of the MMR vaccine as was recommended in the early 1990s in most countries. Furthermore, it was possible to contract measles after having had the appropriate vaccinations. A history of MMR vaccination might explain why this patient did not have the classic symptoms of cough and conjunctivitis and why the initial, somewhat atypical rash developed. After considering all aspects of this patient's presentation, including his exposure history, his clinical presentation, the features of his exanthem, and the salient laboratory findings, the physician believed the best unifying diagnosis was modified measles infection in a previously vaccinated person. One physician stated that the physician first met the patient on the second hospital day. This otherwise healthy man presented with rash and fever during the summer, and thus tickborne infections, such as ehrlichiosis or anaplasmosis, were a possibility. At the time of consultation, the physicians favored a diagnosis of rubella or atypical measles and performed a biopsy of one of the skin lesions. Follow-up: The patient's condition improved with conservative treatment. At the time of discharge, he was no longer considered infectious and was not quarantined. Steps were taken to determine whether others had been exposed to the virus during his time in the hospital clinics and emergency department. The patient was seen by his primary care physician 3 weeks after he was discharged from the hospital. By the time of the visit, his rash and fever had completely resolved. Although he noted decreased exercise tolerance, his fatigue was slowly improving. Laboratory test results at follow-up showed improved blood counts and normalization of liver-function values. The patient was well. A copy of the published article is attached as further documentation of the patient's experience. Additional information has been requested.