Year: 2004
Type: article
Abstract: One week after receiving the measles, mumps, and rubella (MMR) immunisation, 14 month old Kate developed a non-pruritic ''blotchy'' erythematous macular rash.The rash was present over the proximal areas of her arms and legs and was most noticeable during the afternoon.Initially she remained otherwise well, but six days later developed coryzal symptoms and lethargy.Kate's general practitioner (GP) was consulted.There was no significant past medical or family history.She was taking no regular medication and had no known allergies.On examination, apart from the rash and a pink throat, she appeared normal.He prescribed a course of amoxicillin.The GP thought that a viral upper respiratory tract infection was the most likely diagnosis but nevertheless prescribed amoxicillin just in case the rash was caused by a bacterial infection.He also considered the possibility of a reaction to the MMR immunisation, but thought this was unlikely in view of the long history. COMMENTc About one week after the first dose of an MMR immunisation it is common to have symptoms of malaise, fever, and a rash, usually lasting 2-3 days.There is also an increased frequency of febrile convulsions at this time.These effects are likely to relate to the measles component and are less common after the second MMR immunisation. 1The next day Kate developed fever and diarrhoea (without blood or mucus).She also became unsettled and more lethargic.The intermittent fever and rash continued.Her mother and grandmother also developed diarrhoea.The GP was again consulted and a referral was made to the local hospital paediatric unit.In view of the history of diarrhoea in family contacts, the GP considered the most likely diagnosis to be infectious gastroenteritis rather than a side effect of the amoxicillin.He was particularly concerned because Kate looked unwell.On admission to hospital Kate's axillary temperature was 38.7 ˚C and a maculopapular rash was noted (fig 1).The senior house officer assessed Kate and noted a pink throat but no other signs to indicate a focus of infection.Kate was well perfused with no signs of meningitis, but was crying inconsolably at times.There was no hepatosplenomegaly or lymphadenopathy.Examination was otherwise normal.Initial investigations were arranged (table 1).The senior house officer was concerned about the unexplained fever, rash, neutrophilia, and raised C reactive protein (CRP) and so discussed Kate with the registrar on call.They agreed to start intravenous cefotaxime as broad spectrum cover for a possible invasive bacterial infection. COMMENT cIn young children intravenous antibiotics should be started promptly if invasive bacterial disease (such as meningitis or septicaemia) is suspected to minimise the risk of serious complications.Without a clear diagnosis, the organisms that need to be covered include Neisseria meningitides, Escherichia coli, Streptococcus pneumoniae, and Haemophilus influenza type b.These are usually all sensitive to cefotaxime.On the paediatric ward observations every four hours did not suggest any circulatory compromise and it was noted that Kate looked well when apyrexial.The following day the consultant paediatrician reviewed her on the ward round.At that time he found Kate to be apyrexial with no rash.
Institutions: Royal Victoria Infirmary, Newcastle University
Language: English
Topic: Virology and Viral Diseases
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2060153420