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Time Completed: 01:07:02

Final Score 54%

98
82

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Microbiology

Pathogens

Question 74 of 180

A 8 year old unvaccinated girl, originally from Hungary, is brought to ED by her parents who are concerned about a non-itchy rash. She has been off school with a cough, conjunctivitis and a high temperature for the last couple of days and the rash started this morning, appearing first behind her ears and travelling down her trunk, shown below. On examination you note some white spots on her buccal mucosa near her back teeth. Which of the following is the most likely infectious agent:

By Dr. Heinz F. Eichenwald [Public domain], via Wikimedia Commons

(Image by Dr. Heinz F. Eichenwald [Public domain], via Wikimedia Commons)

Answer:

The patient most likely has measles, given the history of a prodromal phase preceding the development of a maculopapular rash associated with Koplik spots.
Virus Measles
Transmission Respiratory droplet route
Incubation period 9 - 12 days
Relation of infectivity to rash Patients are infectious from about 3 days before rash emerges to 4 days after
Relation of infection to immunity Natural infection is followed by lifelong immunity
Clinical features 2 - 4 day prodromal phase (fever, coryza, cough, conjunctivitis), Koplik spots (white papules on buccal mucosa), maculopapular rash appearing first behind the ears and spreading to whole body, rash resolves after 7 - 10 days
Complications Secondary bacterial infection (pneumonia, bronchitis, otitis media), encephalitis, subacute sclerosing panencephalitis
Diagnosis ELISA and immunofluorescence of saliva/blood, viral culture of buccal/nasopharyngeal swab
Treatment Supportive treatment, notifiable disease
Vaccination MMR vaccine given at one year and at preschool age

Transmission and Epidemiology

Measles is transmitted by the respiratory droplet route. The incubation period is about 9 - 12 days and individuals are infectious for about 3 days before the rash emerges. Natural infection is followed by lifelong immunity.

Mortality is rare, but is higher in patients who have HIV, are immunocompromised, malnourished, or are under 2 years old. Measles is rare in countries with a vaccination programme (but has become more prevalent of late due to a failure of uptake of vaccination).

Clinical Features

A prodromal 2 - 4 day coryzal illness (fever, cough, conjunctivitis, irritability) normally occurs associated with Koplik's spots (small white papules found on the buccal mucosa near the first premolars), before a morbilliform maculopapular rash appears, first behind the ears and then spreading downwards to whole body. The rash peels off or fades about about 7 - 10 days.

Complications

Complications may include:

  • secondary bacterial infection
    • pneumonia
    • otitis media
    • bronchitis
  • encephalitis
  • subacute sclerosing panencephalitis
    • a rare, progressive, fatal encephalitis that develops 7 - 10 years after infection, usually in children who had a primary infection before the age of 2
    • a progressive loss of neurological function results in spasticity, seizures and eventually death

Diagnosis

Measles is unlikely in a fully immunised individual. Following assessment, if a diagnosis of measles is considered likely, it is essential to notify the local Health Protection Unit (HPU), and the infection should be confirmed through laboratory investigation. Investigations may include ELISA, immunofluorescence of saliva or blood or viral culture of buccal or nasopharyngeal swab.

Treatment

Treatment is supportive and measles will usually resolve over a course of 7 - 10 days. Antivirals may be considered in patients at particularly high risk.

Prevention

Infected patients should be isolated to prevent spread. Patients are considered infectious for 3 days before the rash emerges and are advised to stay away from school/nursery/work for four days from onset of the rash.

The measles, mumps and rubella vaccination is given at 1 year and at preschool age (three years, four months old).

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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