Measles Presentation in a Toddler

An 18-month-old toddler presents for a sick visit with a chief complaint of recent onset of fever and skin lesions.  Which of the following is most consistent with the presentation of measles (rubeola)? 

A. A 3-day history of anterior cervical lymphadenopathy, significant sore throat, fever with a 1-day history of a fine erythematous skin eruption.  

B. A 3-day history of fever, mild nasal congestion, 

and crankiness followed by resolution of elevated temperature and eruption of a fine pink rash 

C. A 3-day history of cough, conjunctivitis with clear eye discharge, mild sore throat without exudate, diffuse lymphadenopathy and fever, followed by a new onset diffuse maculopapular rash 

D. A 2-day history of fever, mild sore throat, posterior cervical lymphadenopathy, and maculopapular skin lesions.  

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying the pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you 

dissect the anatomy of a test question, so you can better understand 

how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: An 18-month-old toddler present for a sick visit, 

with the chief complaint of recent onset of fever and skin lesions. 

Which of the following is most consistent with the presentation of measles AKA rubeola? 

A: A 3-day history of the anterior cervical lymphadenopathy, significant 

sore throat, and fever with a 1-day history of a fine erythematosus skin eruption. 

B: A 3-day history of fever, mild nasal congestion, and crankiness, followed by resolution of the elevated temperature and eruption of a fine pink rash. 

C: A 3-day history of cough, conjunctivitis with clear eye discharge, mild sore throat without exudate, diffuse lymphadenopathy and fever followed by a new onset diffuse maculopapular rash. 

D: A 2-day history of fever, mild sore throat, posterior cervical lymphadenopathy, and maculopapular skin lesions. 

The correct answer is C: A 3-day history of cough, conjunctivitis 

with clear eye discharge, mild sore throat without exudate, diffuse lymphadenopathy, and fever followed by new-onset diffuse maculopapular rash. 

Where do you start with this question? Being given that we're being asked to identify the clinical presentation of a sick toddler, this is a diagnosis question. 

Some background information. Measles is caused by the rubeola virus and is one of the most contagious infectious diseases ever reported. 

It's many times more contagious than influenza or COVID-19. The number of measles cases has grown recently, typically with the virus entering the U.S., carried by a person who is not immune to measles, who has traveled abroad and imports the virus. 

Most cases of measles occur in children and younger adults who have not been immunized with the MMR vaccine or the measles, mumps, and rubella vaccine. 

The spread of the rubeola virus is via respiratory droplets and has an incubation period of about 10 to 14 days. 

This is a potentially deadly infection, in fact, and the United States, we are in the midst of a rubeola outbreak, and two children and one adult have died as a result of measles. 

Measles infection at the time of this recording, and I suspect those numbers will in fact go up. This is a potential deadly infection, 

with encephalitis and pneumonia among the most serious complications as a result is a possibility of permanent neurologic impairment. 

Or, with this vaccine preventable disease from the encephalitis component. There's also a risk of deafness that can go along with measles infection. 

The clinical presentation of measles includes fever, nasal discharge, cough, generalized lymphadenopathy, conjunctivitis, which is characterized as copious clear discharge, and in other words, super watery eyes. 

But then the conjunctiva are also inflamed. Photophobia and mild pharyngitis. In other words, the first few days of the measles illness, 

it can resemble the clinical presentation of many self-limiting viral infections that we so often see. 

At the same time, kids presenting with measles usually look and act sicker in this pre-rash stage than a child with like, let's say something like rhinovirus or adenovirus. 

You are right. You know, one part from being privileged to being a provider of health care to children now for many decades. Now that I know there's a big difference between a child who's miserable and a child who's really sick, and the miserable child who's got a sore throat and a runny nose and is only 18 months old and can't tell you where it hurts. 

That is the kid that is going to fight you with the with the strength of ten adults. When you want to look in the throat, when you want to look in the ears, that type of thing, that kid is miserable. 

The kids with measles are sick and one of the most terrifying parts 

of examining a child of this age who feels miserable and is also very sick, is often they do not fight you when you go to examine them. 

Now, I don't want to make it sound like I'm some brute in the exam room 

with a toddler. 

However, with a sick kid, look in the back of the throat, you've got to look in the ears. 

You know, you do need to make sure that you can do that. And sometimes it will take having the parent or caregiver giving you some help there. 

You'll learn. You'll learn some tricks over the years to make this as 

least traumatic as it can be to the family and of course, to the child. 

But whenever you have a child who does not object to the physical exam, very often that's a child that's quite ill. And that there are some measles specific findings, like the Koplik spots, and they appear about 2 days before the onset of the rash as white spots with blue rings on the oral mucosa in some, but certainly not all, people with measles, the maculopapular rash that's characteristic of the illness develops 3 to 4 days after the onset of symptoms, and it's usually pretty severe. 

It can coalesce into a generalized erythema. 

As I've mentioned, there are other rash-producing viral illnesses we see with kids. And one of the key points with measles is the kids are so sick that they often developed a what's colloquially called a 100-mile stare. 

The kid with measles just stares off into space during the exam, and one more time will often not resist examining them. 

The duration of uncomplicated measles is about 10 to 14 days and much longer, obviously with measles complications. 

Intervention with measles is largely supportive and includes the management of complications as well as vitamin A supplementation. 

Just a caveat. Vitamin A supplementation is used during measles infection, but not to prevent measles infection. 

This is a reportable disease to your local or regional public health department. And, who can provide great guidance on confirmatory testing of the diagnosis. 

And as well, in effort to prevent community spread. And with this information is in mind, let's take a look at the question and answers.  

An 18-month-old toddler presents for a sick visit with the chief complaint of recent onset fever and skin lesions. 

Which of the following is most consistent with the presentation of measles, AKA rubeola? 

A: A 3-day history of the anterior cervical lymphadenopathy, significant 

sore throat, and fever with a 1-day history of a fine erythematosus skin eruption. 

This is incorrect, and part of this is, as I've highlighted in other, podcasts, the timing is way off for this to be measles. And this is the description of scarlet fever, which is in essence, strep throat with a skin eruption. 

Timing, timing, timing. That's what you want to listen to when you're doing differential diagnosis with scarlet fever. 

The sore throat is generally present for about 2 to 3 days, and the predominant feature is then followed by a sandpaper-like rash. 

And I have seen countless kids over the years with scarlet fever. Every single time I see a child with scarlet fever, I'll say to myself, that rash is not going to feel like sandpaper. 

Then I run my fingers over the rash and son of a gun. It feels like very fine sandpaper for or like a fine emery board, you know, like a nail file type of thing. 

The other part of this, with the difference between the sore throat 

that goes along with measles versus the sore throat that goes along with scarlet fever. 

The sore throat that goes along with scarlet fever is the predominant 

presenting chief complaint. 

And the throat does look pretty horrible because it's actually pharyngitis that we see with group A beta hemolytic strep infection.  
 
B: A 3-day history of fever, mild nasal congestion, and crankiness, followed by resolution of the elevated temperature and eruption of a fine pink rash. 

This is the classic presentation of roseola. The child is often remarkably febrile for a few days, but not terribly sick. 

This is what you'll hear from parents or caregivers. Temp 104 on Monday, it was 103.8 on Tuesday, it was 104 again on Wednesday. 

But I didn't bring the baby in because she still eating. She's still drinking. 

She's a little cranky and a little clingy, but she's just not that sick. 

And then on Thursday, day four, fever goes away. Rash erupts. 

So remember that with roseola: fever, fever, fever. 

No fever, rash. That's usually how it presents. And roseola also nearly always occurs in younger children. 

It is really uncommon to even have a kid who's 4 or 5 years old. Roseola is highly contagious. Most kids pick it up when they're 

in the toddler years, if not earlier. 

Option C: A 3-day history of cough, conjunctivitis with clear eye discharge, mild sore throat without exudate, diffuse lymphadenopathy and fever followed by a new onset diffuse maculopapular rash. 

This is, of course, the correct answer. One of the reasons there's often a delay in measles  diagnosis is because, as I said earlier, it presents in a manner similar to many other common viral illnesses that are particularly seen in childhood. 

Once the rash presents after the child, in this case has been ill for a few days, the diagnosis is then finally considered. 

Following public health alerts is an important part of clinical practice 

to not only get advice on how to confirm the diagnosis with laboratory testing, but also measures to help prevent the spread of measles because this is so darn contagious. 

D: A 2-day history of fever, mild sore throat, posterior cervical lymphadenopathy, and maculopapular skin lesions. 

This describes a clinical presentation of rubella or German measles. 

This is, of course, another vaccine preventable disease and is actually the R in the MMR. 

While measles carries the risk of severe illness, potential disability and death. 

Rubella is actually a pretty mild illness, usually passing in about 3 days. So why do we bother immunizing kids against rubella-well I shouldn't just say kids. 

I should say adults need to be up to date with their MMR vaccine as well. Why do we bother immunizing against rubella? 

Because it is a highly teratogenic virus and when contracted during pregnancy, there is a risk of blindness, developmental disability, 

spontaneous abortion. 

The list goes on and on and on about the problems that can occur with rubella during pregnancy. 

There's actually no good trimester of pregnancy to contract rubella in. 

Key takeaway, as I've mentioned timing of signs and symptoms and onset is key to diagnosis, as we can see in these four cases. 

All have fever, all have skin eruptions. But the causative organisms and the potential outcomes are quite different. 

Measles prevention via the use of the MMR vaccine and immune globulin even post-exposure will be covered in another podcast. 

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