Cough - Case 4-3: 7-Month-Old Girl
Cough - Case 4-3: 7-Month-Old Girl: Excerpt from Pediatric Complaints and Diagnostic Dilemmas
I. History of Present Illness
A 7-month-old girl was well until 4 days before presentation, when she developed
a cough with fevers to 40.5
°C. On the day of presentation, she developed wheezing and a rash on her trunk
and face. This rash began on her chest and spread to her face. Over the 4 days,
her cough had increased significantly. She received nebulized albuterol twice
at home without relief. Her oral intake and urine output were poor.
II. Past Medical History
She was the full-term product of an uncomplicated vaginal delivery. She had been
to the emergency department three times for wheezing episodes. She was
currently receiving only nebulized albuterol. At the time of presentation, the
patient and her family were living in a shelter. A roommate at the shelter was
recently hospitalized with a rash, fever, and pneumonia.
III. Physical Examination
T, 40.6°C; RR, 60/min; HR, 168 bpm; BP, 102/55 mm Hg; SpO2, 99% in room air
Weight, 50th percentile; height, 75th to 90th percentile
Initial examination revealed an alert baby who was crying but consolable. She
appeared slightly pale. Physical examination was notable for an erythematous
right tympanic membrane and bilaterally injected conjunctiva with yellow
discharge. She had moderate rhinorrhea and some notable buccal thrush. Her
oropharynx was mildly erythematous. The chest examination was remarkable for an
elevated respiratory rate, but there were no retractions. She had fine
expiratory wheezes bilaterally, with decreased breath sounds at both bases. Her
skin exhibited a fine, erythematous, blanching maculopapular rash on her face
and torso (Fig. 4-3) and, to a lesser degree, on her extremities. Her palms and
soles were spared. The rash appeared confluent in her perineal area and torso.
The remainder of her physical examination was unremarkable.
IV. Diagnostic Studies
Laboratory analysis revealed a peripheral blood count of 10,900 WBCs/mm3, with 41% segmented neutrophils, 50% lymphocytes, 8% monocytes, and no band
forms. The hemoglobin was 10.6 g/dL, and there were 290,000 platelets/mm
3. A urinalysis was normal, and a chest roentgenogram revealed mild
hyperinflation and right middle lobe atelectasis with some peribronchial
cuffing.
V. Course of Illness
The patient received two nebulized albuterol treatments without significant
change in her respiratory rate. Blood and urine cultures were sent and revealed
no growth. Her fever resolved over the next 2 days, and her respiratory status
began to normalize. Her rash also began to fade, and she was discharged back to
the shelter after a 4-day hospitalization. Examination of the rash (see Fig.
4-3) suggested a diagnosis that was confirmed by studies on blood samples sent
during her hospitalization.
Discussion: Case 4-3
I. Differential Diagnosis
Viral infections are the most common cause of a cough in infancy, with
respiratory syncytial virus, adenovirus, and influenza and parainfluenza
viruses among the leading agents. In infancy, these viruses also commonly
produce lower airways disease, so that bronchiolitis quite often accompanies
the cough. Infants with bronchiolitis have decreased aeration with diffuse
rales and wheezing appreciated on auscultation. Fever is common, as is profuse
rhinorrhea.
Other infectious etiologies are possible and should always be considered in the
differential diagnosis; they include
C. trachomatis, pertussis, and bacterial pneumonia. Less commonly, infants present with
pulmonary tuberculosis or a fungal infection. Rarely, infectious entities such
as measles or parasitic infections manifest with cough.
Although cough can be the presenting symptom in many cases of congenital
malformations, this case strongly suggests an infectious etiology. The features
of this case that prompted additional evaluation included the rash and the
associated respiratory findings.
II. Diagnosis
The rash was characteristic of measles (see Fig. 4-3). Antibody titers to
measles were sent on admission and were negative. Repeat titers were sent
before her discharge on hospital day 4. Immunoglobulin M (IgM) antibodies
specific for measles were found to be positive.
The diagnosis is measles.
III. Incidence and Epidemiology
Measles is the infectious condition caused by the rubeola virus, an RNA virus of
the family Paramyxoviridae. Before the introduction of the measles vaccine in
1963, some 200,000 to 300,000 cases of measles were seen each year in the
United States. Since then, this has decreased by 99%. Currently, measles is
reported rarely in preschool children, some of whom are too young to be
vaccinated. Infrequently, cases of primary vaccine failure are reported.
Measles is spread as an airborne virus, and infection results from direct
contact with droplets from the respiratory secretions of infected patients. The
typical incubation period is 10 days. Children are most infectious when cough
and coryza are at their peak, which occurs during the late prodromal phase.
Children are considered contagious from several days before until 5 days after
the onset of the rash. The mortality rate for measles in the United States is 1
in 3,000 cases.
IV. Clinical Presentation
The prodromal phase begins with 3 to 5 days of malaise, fever, cough, coryza,
and conjunctivitis. These symptoms increase over the course of the prodromal
phase. Fevers vary from 39.4
° to 40.6°C and usually peak as the exanthem begins. Just before the development of the
exanthem, Koplik
's spots are noted. These are bluish spots on a red base that are found on the
buccal mucosa. Koplik
's spots are pathognomonic of measles. The exanthem begins as Koplik's spots begin to slough. The rash typically begins on the face and then moves in
a caudal direction. The rash is initially erythematous and maculopapular but
then becomes confluent. The rash usually lasts 5 to 7 days.
Other symptoms can include pharyngitis, lymphadenopathy, splenomegaly, diarrhea,
vomiting, and abdominal pain. With typical measles, patients are ill for 7 to
10 days. However, complications can occur and include pneumonia, encephalitis,
myocarditis, pericarditis, appendicitis, and corneal ulcerations. Subacute
sclerosing panencephalitis (SSPE) is an uncommon neurologic complication of
measles infection. SSPE consists of a degenerative central nervous system
process that is associated with a persistent measles infection.
V. Diagnostic Approach
The diagnosis of measles is based on the classic clinical criteria. The
following studies may be used to confirm a suspected diagnosis.
Viral culture. Viral isolation is not commonly used, because it is difficult to perform.
However, this study may be important in the immunocompromised patient.
Immunofluorescence. Immunofluorescent staining for measles antigen may be performed on
nasopharyngeal washings.
Serologic titers. If there is a question about the diagnosis from a clinical standpoint, one can
look for a serologic response to the viral infection. Antibodies can initially
be seen on days 1 to 3 of the exanthem and reach their peak levels in 2 to 6
weeks. Therefore, if serologic confirmation is necessary, patients should have
both acute and convalescent titers sent. A four-fold rise in the measles titer
over time, or the presence of measles-specific IgM antibodies, establishes the
diagnosis.
VI. Treatment
In uncomplicated measles, patients require only supportive care, including
antipyretics and fluids. Antibiotics are necessary only in cases of bacterial
superinfection, particularly pneumonia. Typical organisms causing a
superinfected bacterial pneumonia include
Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Streptococcus pyogenes.
VII. References
1. Gerson AA. Measles virus (rubeola). In: Mandell GL, Bennett JE, Dolin R, eds.
Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 5th ed. Philadelphia: Churchill Livingstone, 2000:1801–1807.
2. Rosa C. Rubella and rubeola. Semin Perinatol 1998;22:318–322
3. Taber LH, Demmier GJ. Measles (rubeola). In: Oski FA, DeAngelis CD, Feigin
RD, McMillan JA, et al., eds.
Principles and practice of pediatrics, 2nd ed. Philadelphia: JB Lippincott, 1994:1340–1343.
4. West CE. Vitamin A and measles. Nutr Rev 2000;58:S46–S54.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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