IDENTIFYING DATA FV 6 months old Male Roman Catholic Filipino
CHIEF COMPLAINT: Fever and rashes 6 months old Fever Rash
Slide 3
History of Present Illness 6 days PTA First dose of measles
vaccine 5 days PTA Fever (Tmax 38.8 oC ) Temporarily relieved by
paracetamol (Tempra) drops 100 mg/ml 1ml every 4 hours
(14mg/kg/dose)
Slide 4
3 days PTA Still with fever Erythematous maculopapular rashes
on the back of the ears and forehead 2 days PTA Spread of the
maculopapular rashes to the face and neck area Colds watery nasal
discharge Non-productive cough Consult at TMC satellite clinic CBC
with platelet count (Hgb 119, Hct 0.35, WBC 15.04, Neutrophil 29.1,
Lymphocytes 63.3, Platelet 305) Sent home: Ambroxol (dose) and
cetirizine (dose)
Slide 5
1 day PTA Progression in severity of the cough Persistence of
colds Eye redness and discharge (pagmumuta) Lysis of the fever
spread of the maculopapular rashes to the trunk and lower
extremities Irritable (increased crying) Day of consult Decrease in
oral fluid intake Difficulty of breathing Admission
Slide 6
Temporal Profile
Slide 7
ROS GENERAL: No weight loss, no decrease in activity HEENT: see
HPI CARDIOVASCULAR: No palpitations RESPIRATORY: see HPI
GASTROINTESTINAL: No vomiting, no diarrhea EXTREMITIES: see HPI 6
months old Fever Maculopapular Rash (cephalocaudal) Cough Colds
Conjunctivitis Decrease in oral intake Difficulty of breathing
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PMH No known allergies Previous illness: UTI at 2 mos Given
unrecalled dose of cefixime without resolution of infection At 4
mos, change of antibiotic to cefuroxime with unrecalled dose with
subsequent resolution 6 months old Fever Maculopapular Rash
(cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake
Difficulty of breathing
Slide 9
Birth History Born full term, via LTCS II, to a 28 year old
G3P3 (3003) at Unciano Medical Center Birth weight of 3kg No
complications during pregnancy or delivery. 6 months old Fever
Maculopapular Rash (cephalocaudal) Cough Colds Conjunctivitis
Decrease in oral intake Difficulty of breathing
Slide 10
Immunization History BCG:1 dose Penta:3 doses OPV:3 doses Hepa
B:1 dose Measles: 1 dose Varicella: 1 dose Hib: 1 dose PCV:1 dose 6
months old Fever Rash (Cephalocaudal) Cough Colds Conjunctivitis
Decrease in oral intake Difficulty of breathing Measles vaccine (6
days prior)
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Nutritional History Breastfed exclusively until 3 months old
Formula feeding (Enfalac) started at 3 months old Weaning at 6
months of age - started on mashed vegetables and Cerelac Normally
eats well consuming 2-4 oz per feeding around 6x/day 6 months old
Fever Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in
oral intake Difficulty of breathing Measles vaccine (6 days
prior)
Slide 12
Developmental History At par with age Motor: able to sit with
support Language: imitate sounds, babble incomprehensible syllables
Social: stretches arms when he wants to be taken and indicates
likes and dislikes with actions 6 months old Fever Rash
(Cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake
Difficulty of breathing Measles vaccine (6 days prior)
Slide 13
Family History No hypertension, diabetes, asthma, allergies,
cancer No other family member with similar symptoms 6 months old
Fever Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in
oral intake Difficulty of breathing Measles vaccine (6 days
prior)
Slide 14
Personal, Social, and Environmental History Lives at home with
his parents in Rosario, Pasig 10 people at home (mother, father, 2
older siblings, maternal uncle and his wife, the mothers cousin,
and great aunt, nanny, patient) 4-story aparment-type complex; each
family has their own room Father: property manager Mother:
accounting assistant No smokers in the household 6 months old Fever
Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral
intake Difficulty of breathing Measles vaccine (6 days prior)
Slide 15
Personal, Social, and Environmental History Financial problems
due to the increasing length of the hospital stay and medications
Everyone in the household contributes to the hospital expenses
(mothers older brother shares a lot) 6 months old Fever Rash
(cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake
Difficulty of breathing Measles vaccine (6 days prior)
Slide 16
Stakeholder Analysis StakeholderRoleInterest in Issue Level of
Influence FatherPrimary Breadwinner High MotherPrimary Caregiver
High Uncle and wifeBreadwinnerModerateHigh
NannyCaregiverModerateLow SiblingsHighLow Great
auntCaregiverModerateLow Mothers cousin Low
Slide 17
Salient Features SUBJECTIVEOBJECTIVE 6 months old Fever Rash
(cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake
Difficulty of breathing Measles vaccine (6 days prior)
Slide 18
Temporal Profile
Slide 19
Physical Examination General Survey: Awake, alert, not in
respiratory distress Vital Signs: BP 90/60 mmhg CR 126 bpm RR 31
cpm T 39.9C (febrile) Anthropometric: Wt 7.0 kg(z score > -2) Ht
86 cm(z score < 3) HC: 38cm (z score < -3) AC: 40cm CC: 39cm
High grade fever
Slide 20
Physical Examination Skin Pinkish in color (+) Erythematous
maculopapular rashes on the face and trunk Soft/supple skin High
grade fever Erythematous maculopapular rashes on face and
trunk
Slide 21
Physical Examination HEENT Head: No deformities of the head
Eyes: Equal, non-sunken almond-shaped eyes; anicteric sclerae, pink
conjunctivae, pupils 2-3mm, EBRTL, no discharge/swelling noted, no
cataracts Ears: Normal-looking pinnae, patent ear canal with no
swelling or discharge Nose: Midline, intact nasal septum, patent
nares and no nasal discharge; no alar flaring; no nasal congestion
Mouth: Pink, moist lips, tongue and buccal mucosa; no cleft
lip/palate High grade fever Erythematous maculopapular rashes on
face and trunk No alar flaring, dry lips
Slide 22
Physical Examination Cardiovascular Adynamic precordium; no
deformities; good S1/S2; regular rate and rhythm; no heart murmur
Pulmonary (+) Intercostal retractions; equal chest expansion; (+)
bilateral rales/crackles High grade fever Erythematous
maculopapular rashes on face and trunk No alar flaring, dry lips
Intercostal retractions Harsh breath sounds Bilateral
rales/crackles
Slide 23
Physical Examination Abdomen No masses/lesions; normoactive
bowel sounds; soft, non-tender Extremities No edema, no cyanosis,
full and equal pulses, CRT
Slide 24
Physical Examination Neurological Exam Appropriate for age
Cranial nerves: I: Not tested II: Pupils 2-3 mm bilaterally
reactive to light III, IV, and VI: Full range of motion of
extraocular muscles VI: (+) Corneal reflex VII: No facial asymmetry
VIII: follows sounds IX and X: (+) gag reflex XI: Can shrug
shoulders XII: Tongue midline Motor: exhibits spontaneous movement
on all extremities Cerebellar: cannot be assessed Reflexes: 2++ on
all extremities Sensory: reacts to pain High grade fever
Erythematous maculopapular rashes on face and trunk No alar
flaring, dry lips Intercostal retractions Harsh breath sounds
Bilateral rales/crackles
Slide 25
Salient Features SUBJECTIVEOBJECTIVE 6 months old Fever (5 th
day) Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in
oral intake Difficulty of breathing Measles vaccine (6 days prior)
High grade fever Erythematous maculopapular rashes on face and
trunk No alar flaring No retractions Bilateral rales/crackles
Slide 26
Problem List (?)
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Slide 28
Differentials Differential #1: MEASLES Fever Rashes Colds Cough
Conjunctivi tis Irritability (+) Measles Vaccine Harsh breath
sounds Bilateral crackles Rule InRule Out Presents with: Fever Rash
(Cephalocaudal spread) Coryza Cough Conjunctivitis Complication of
Pneumonia Measles IgG/IgM results Cannot be totally ruled out
Laboratory findings: Diagnosis of measles is mainly clinical and
laboratory exams are not routinely ordered. CBC: Slightly decreased
hemoglobin, hematocrit, RBC with slightly increased WBC PRESENTER:
This will serve as our theoretical discussion. NOTE: Measles
Rubeola, Tigdas, an acute viral infection due to measles virus:
Genus Morbillivirus, Family Paramyxoviridae. Incubation stage
Prodromal stage (3cs, preceded symptoms by Koplik Spots,
low-moderate fever) Stage of cephalo-caudal Rash and High fever
PRESENTER: This will serve as our theoretical discussion. NOTE:
Diagnostic management for measles IgM is detectable for 1mo but is
limited in the first 72 hr of the rash illness. IgG antibodies
detectable by about a week after rash onset. It is recommended that
specimens be drawn on the seventh day after rash onset. Diagnostic
is mainly clinical.
Slide 29
Measles Rash
Slide 30
Differentials Differential #2: Varicella Rule InRule Out
Presents with: Low grade fever Anorexia Headache Rash (vesicle on
an erythematous base, with significant pruritus) dew on a rose
petal Emerge in various asynchronous crops Rash lasts 12-21 days
Does not present with: Same description of rash (pustule with
erythematous base) Trunk to extremities Fever Rashes Colds Cough
Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath
sounds Bilateral crackles Laboratory findings: CBC: Non-specific
CBC findings. May show a decrease in WBC with lymphocytic
predominance as found in other viral illnesses. Diagnosis is mainly
clinical.
Slide 31
Varicella Rash
Slide 32
Differentials Differential #3: Rubella Rule InRule Out Presents
with: Low grade fever Rash Does not present with: Same description
of rash Anorexia Maculopapular rash appears on face and neck and
spreads to the rest of the body Spares the palms and soles Fades
after 3 days Tender posterior acuricular adenopathy Fever Rashes
Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh
breath sounds Bilateral crackles Laboratory findings: CBC:
Non-specific CBC findings. May show a decrease in WBC with
lymphocytic predominance as found in other viral illnesses.
Diagnosis is mainly clinical.
Slide 33
Rubella Rash
Slide 34
Differentials Differential #4: Roseola Rule InRule Out Presents
with: Fever Diffuse macular or maculopapular rash Does not present
with: Presentation of fever Same description of rash Well looking
baby Condition improves with appearance of rash Fever Rashes Colds
Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath
sounds Bilateral crackles Laboratory findings: CBC: Slightly
decreased hemoglobin, hematocrit, RBC with slightly increased
WBC
Slide 35
Roseola Rash
Slide 36
Differentials Differential #5: Hand Foot & Mouth Disease
Rule InRule Out Presents with: Low-grade fever Rash Does not
present with: Same description of rash malaise, anorexia, and
posterior pharyngeal ulcerations Oral lesions on whole
palate/tongue Maculopapular lesions on hands and feet (progresses
to vesicles and then ulcerations) Fever Rashes Colds Cough
Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath
sounds Bilateral crackles Laboratory findings: CBC: Non-specific
CBC findings. May show a decrease in WBC with lymphocytic
predominance as found in other viral illnesses. Diagnosis is mainly
clinical.
Slide 37
Hand, Foot, and Mouth Rash
Slide 38
Differentials Differential #6: Dengue Rule InRule Out Presents
with: Fever Defervescence rash (isles of white in a sea of red)
Does not present with: Same description of rash Anorexia Abdominal
pain Bleeding episodes CBC results decreasing platelet count with
hemoconcentration Fever Rashes Colds Cough Conjunctiviti s
Irritability (+) Measles Vaccine Harsh breath sounds Bilateral
crackles Laboratory findings: CBC: Decrease in WBC,
hemoconcentration, and decrease in platelet. Lymphocytic
predominance as found in other viral illnesses. May request for
Dengue NS1 and Dengue Blot test to confirm diagnosis.
Slide 39
Dengue Rash
Slide 40
Differentials Differential #7: Chikungunya Rule InRule Out
Presents with: Fever Rash Conjunctivitis Does not present with:
Presentation of rash Anorexia Vomiting Joint pains Fever Rashes
Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh
breath sounds Bilateral crackles Laboratory findings: CBC: CBC:
Decrease in WBC and slight decrease in platelet. Lymphocytic
predominance as found in other viral illnesses.
Slide 41
Chikungunya Rash
Slide 42
Primary Working Impression Rubeola Pneumonia, Severe
Generalized inflammation Epithelial cells (skin, conjunctivae, and
the mucous membranes of the nasopharynx, bronchi, and intestinal
tract) Generalized inflammation Epithelial cells (skin,
conjunctivae, and the mucous membranes of the nasopharynx, bronchi,
and intestinal tract) Complications Otitis media most common (All
ages less than 5 years) Strep, H. influenza, M. catarrhalis
Pneumonia Leading cause of mortality H.influenza, Strep May be
viral or due to bacterial lung infection Encephalitis From measles
virus itself Laryngotracheobronchitis Complications Otitis media
most common (All ages less than 5 years) Strep, H. influenza, M.
catarrhalis Pneumonia Leading cause of mortality H.influenza, Strep
May be viral or due to bacterial lung infection Encephalitis From
measles virus itself Laryngotracheobronchitis
Slide 43
Slide 44
Hospital Day 1 SubjectiveObjectiveAssessmentPlan Day 6 of
illness crying but consolable, weak looking Fever (39.9C) slightly
sunken eyeballs, bilateral conjunctivitis, dry lips bilateral rales
and shallow subcostal retractions generalized maculopapular rash
Measles Pneumonia CBC with PC Measles IgG and IgM Chest Xray AP Lat
IVF: D5LR 350ml to run at 44ml/hour Paracetamol 100mg/ml
(Ibuprofen) Salbutamol + Ipratropium (Combivent) neb Cefuroxime
200mg/IV every 8 hours (86 mg/kg/day Stages of Measles Incubation
stage Prodromal stage With enanthem Final stage Maculopapular rash
High fever Stages of Measles Incubation stage Prodromal stage With
enanthem Final stage Maculopapular rash High fever
Differentials Measles Immunoglobulin G and Immunoglobulin M
Laboratory findings: Measles IgG/IgM: IgG (+): past infection IgM:
current infection Measles IgM (ELISA)0.541 Measles IgG0.217 1.1
positive
Slide 47
Chest Xray: Interstitial Pneumonia, bilateral
Slide 48
Hospital Day 1 SubjectiveObjectiveAssessmentPlan Day 6 of
illness crying but consolable, weak looking Fever (39.9C) slightly
sunken eyeballs, bilateral conjunctivitis, dry lips bilateral rales
and shallow subcostal retractions generalized maculopapular rash
Measles Pneumonia CBC with PC Measles IgG and IgM Chest Xray AP Lat
IVF: D5LR 350ml to run at 44ml/hour Paracetamol 100mg/ml
(Ibuprofen) Salbutamol + Ipratropium (Combivent) neb Cefuroxime
200mg/IV every 8 hours (86 mg/kg/day Supportive management
Antiviral therapy is not effective Prophylactic antimicrobial
therapy - not indicated Goals of therapy: Hydration Oxygenation
Comfort Supportive management Antiviral therapy is not effective
Prophylactic antimicrobial therapy - not indicated Goals of
therapy: Hydration Oxygenation Comfort
Slide 49
Recommendations for Vitamin A Treatment of Children with
Measles INDICATIONS: Children 6 mo to 2 yr of age hospitalized with
measles and its complications (e.g., croup, pneumonia, and
diarrhea) Children >6 mo of age with measles who are not already
receiving vitamin A supplementation and who have any of the
following risk factors: Immunodeficiency Clinical evidence of
vitamin A deficiency Impaired intestinal absorption Moderate to
severe malnutrition Recent immigration from areas where high
mortality rates attributed to measles have been observed From the
American Academy of Pediatrics, Committee on Infectious Disease:
Vitamin A treatment of measles. Pediatrics
Slide 50
REGIMEN Parenteral and oral formulations of vitamin A are
available in the USA. The recommended dosage, administered as a
capsule, is: Single dose of 200,000 IU orally for children 1 yr of
age (100,000 IU for children 6 mo to 1 yr of age) The dose should
be repeated the next day and again 4 wk later for children with
ophthalmologic evidence of vitamin A deficiency From the American
Academy of Pediatrics, Committee on Infectious Disease: Vitamin A
treatment of measles. Pediatrics
Slide 51
Hospital Day 2 SubjectiveObjectiveAssessmentPlan Day 7 of
illness Irritable Cough Soft stools x2 Tachypneic 60s-80s
Tachycardic 145-204 bpm O2 sat 90-91% 96% after O2 support
Hyperemic conjunctiva, hyperemic posterior pharyngeal walls
bilateral rales and shallow subcostal retractions generalized
maculopapular rash Measles Pneumonia Paracetamol, Cefuroxime,
Shifted Salbutamol + Ipratropium (Combivent) neb to NSS neb q2hrs
Zinc drops BID O2 support via facemask at 5 lpm 10-15 lpm Advised
PICU admission, family refused due to financial limitations OGT
inserted
Slide 52
Hospital Day 3 SubjectiveObjectiveAssessmentPlan Day 8 of
illness Febrile episodes able to tolerate oral feeding every 2-3
hours Adequate urine output and bowel movement Tachypneic episodes
noted; no desaturations Hyperemic conjunctiva, hyperemic posterior
pharyngeal walls bilateral rales and shallow subcostal retractions
generalized maculopapular rash Measles Pneumonia Paracetamol,
Cefuroxime NSS neb q2hrs Zinc drops BID O2 support via facemask
nasal cannula at 3 lpm OGT removed IVF at maintenance +10%
rate
Slide 53
Hospital Day 4 SubjectiveObjectiveAssessmentPlan Day 9 of
illness Febrile episodes + chills able to tolerate oral feeding
every 2-3 hours Adequate urine output and bowel movement Tachypneic
episodes noted; no desaturations Hyperemic conjunctiva, hyperemic
posterior pharyngeal walls bilateral rales and shallow subcostal
retractions generalized maculopapular rash Measles Pneumonia
Referred to Infectious Disease Cefuroxime shifted to
Piperacillin-Tazobactam 500mg/IV every 6 hours (258 mg/kg/day)
Paracetamol Shifted Salbutamol + Ipratropium (Combivent) neb to NSS
neb q2hrs Zinc drops BID O2 support via facemask nasal cannula at 3
lpm OGT removed IVF at maintenance +10% rate
Chest Xray: Interval progression of bilateral pneumonia
Slide 56
Slide 57
WHAT IS THIS PICTURE?
Slide 58
Slide 59
Case Definition Clinical case definition Any person in whom a
clinician suspects measles infection Any person with fever,
maculopapular rash, cough, coryza, conjunctivitis Laboratory
criteria for diagnosis 4x increase in antibody titer, isolation of
measles virus, or presence of IgM antibodies
Slide 60
What is considered an outbreak? DOH: 1 case, suspected or
confirmed, in a community where there was no case in the past 1
case per 2 weeks for 2 consecutive weeks WHO Number of cases
observed is greater than the number normally expected in the same
geographic area for the same period of time
Slide 61
Outbreak Timeline (Metro Manila) 25 cases 2012 179 cases Dec 10
2013 760cases Jan 11 2014 DOH Declared Outbreak Jan 4, 2014 21
barangays In 9 cities 716% increase 416 % increase DOH statistics
Only 6% of the reported Cases are confirmed
Slide 62
Philippines YearConfirmed measles cases Incidence (per 1
million) Deaths due to measles 20088749.88 2009149016.610
2010638868.234 2011655569.128 2012149915.55 2013172417.9721 Source:
WHO. Country Profile-Measles Elimination.
Slide 63
DOH National Epidemiology Center Jan 1 Dec 14, 2014 1,724 cases
and 21 deaths Majority came from Metro Manila (744 cases) 13/17
regions of the Philippines have measles case increase 2013 (NCR)
416 confirmed cases 1568 % increase! 2012 (NCR) 25 confirmed cases
Las Pinas (78), Manila (72), Muntinlupa (65), Caloocan (45),
Paranaque (32), Malabon (31) Urbanized, congested area High
mobility of the residents Supposedly good EPI coverage
Slide 64
Source: WHO. Country Profile-Measles Elimination.
Slide 65
Population at Risk Children under age 5 years old Higher
percentage of death due to measles complication 158,000 people died
from measles in 2011 Pregnant women Immunocompromised
Slide 66
Slide 67
MCV2 routine coverage: the level of coverage by the second dose
of the measles-containing vaccine, as reported in the annual
WHO/UNICEF Joint Reporting Form on Immunization.
Slide 68
Goals Herd Immunity Vaccination coverage of no less than 95%
The Iligtas sa Tigdas ang Pinas program in 2011 only covered 84% of
the population (15,649,907) MR vaccine 16% (~3million) were
unvaccinated or in 2 years since at 84% coverage, 6 million were
unvaccinated Measles Free by 2017 (WHO) 1 case per 1 million
population
Slide 69
Vaccination Measles At 9 months At 6 months during outbreaks
Maternal antibodies may have dwindled already MMR 2 doses 1 dose
90% immunity Booster at 12-18 (15) months 2 doses almost 100%
immunity At 4-6 years of age Some children who have been vaccinated
still got infected 2-3% may not develop antibodies Some parents
refuse vaccination Religious belief Transfer of residence
Slide 70
Government Response Vaccination It will take a couple of weeks
before they develop immunity Mass Immunization Campaign that aims
to cover children