ID Case Presentation Michael Eskander, PGY-3 Dr. Lanny Hsieh 8/7/2014

HPI CC: “Flu-like symptoms” HPI: 45YO Hispanic male with multiple-day history of generalized fatigue, malaise, and fatigue stating he cannot even get out of bed. Then developed productive, non-bloody cough associated with rhinorrhea and frontal sinus headaches. Associated with night sweats and subjective fevers at home Weight loss of unquantifiable amount for a few months – may be due to loss of appetite

HPI + left lateral neck pain. - HA No photo-/phonophobia, No blurry vision + profuse, watery, nonbloody diarrhea ~3x/day No sick contacts, recent travel, camping/tick bites - stiffness or tenderness of medium/large joints Also notes a rash that began on the top of his forehead and appeared to have spread down his body involving his chest, then abdomen and legs Significant desquamation of his bilateral palms and dorsum of feet with associated swelling and tightness surrounding the digits. Believes that he received all his childhood vaccinations but has not seen a physician and is unclear of whether he was able to receive booster vaccinations.

History PMHx: Incarcerated from : at that time he was found to be PPD positive and was treated for latent with likely isoniazid x 6 months. Never had active TB. DM2 – on insulin HTN OUTPATIENT MEDS: Metformin 500 mg orally 2 times a day Lantus Regular insulin correctional scale

History Family History: Dad: HTN, DM. ESRD on HD Mom: HTN, DM Social History: Etoh: history of significant binge drinking 4-5 years. currently social drinking. Quit 3 years ago. Tobacco: 1-2ppd x years. currently smoking 1ppd. IVDU: denies. Living Status: Santa Ana with wife. Allergies: No Known Allergies

Physical Vital Signs: Tc: 37.5 HR: 100 BP: 119/60 RR: 32 SpO2: 92% on NC Gen NAD. AAO x3 HEENT: EOMI PERRLA anicteric sclera. Multiple tender lymph nodes in the posterior cervical chain. dry oral mucosal. no nuchal rigidity. CARD: RRR no m/r/g PULM: CTAB no w/r/c ABD: Soft NT/ND positive BS. EXT: no c/c/e. 2+ distal pulses. Soft tissue swelling of the bi- lateral hands. NEURO: CN II-XII intact. no focal motor or sensory deficits. Skin: Multiple bright red punctate nonblanchable lesions overlying the lateral aspect of the bi-lateral feet. Diffuse scaly erythema overlying the entire body. Desquamation of the bilateral palms with shortened ragged nails.

Labs Lactate: | 86 | < 413 Ca: | 26 | 1.2 WBC: 5.6 / Hb: 17.1 / Hct: 50.1 / Plt: Diff: N:4.3% L:0.4% Mo:0.9% Eo:0.0% Baso:0.0% Prot: 7.3 / Alb: 3.1 / Bili: 1.3 / AST: 63 / ALT: 164 / AlkPhos: 545 UA: >1000 Glucose, +Ketones, no other abnormalities

Imaging

Ddx Common cold Viral syndrome - Rhinovirus, parainfluenza, influenza, adenovirus, RSV, parvovirus B19 Dengue fever (travelers) Measles (Rubeola) VZV Scarlet fever Rickettsial infection (campers) Drug eruption HSP – IgA vasculitis

Hospital Course ED: Vanc/Zosyn. IVF rehydration. HOD #1: - Vanc/Zosyn Stopped, Hyponatremia resolved RSV, Influenza A+B: negative Sputum AFB negative x2 HIV: Negative TPA: Negative C diff.: Negative CK, Plasma: 25 IU/L C Reactive Protein, Plasma: 7.4* MG/DL Sedimentation Rate: 38 MM/HR R. rickettsii IgG: Neg R. rickettsii IgM: Neg R. typhi IgG: Neg R. typhi IgM: Neg Quant. TB Gold: Neg Hepatitis C IgG: Reactive A1C: 14.4 Measles IgG: 2.58* Measles IgM: >40 (>=20 positive) Measles PCR positive

Measles Classical Manifestations: Incubation, Prodrome, Exanthem, Recovery Incubation – usually 8-10 days Prodrome – Fever, malaise, anorexia followed by conjunctivitis, coryza, and cough Koplik’s spots: 1-3mm whitish, grayish, or bluish elevations with erythematous base Exanthem – maculopapular, blanching rash beginning on the face and spreading cephalocaudally and centrifugally to involve the neck, upper trunk, lower trunk and extremities Recovery – 48hrs following exanthem. Cough may persist. Immunity occurs.

Measles Koplik’s Spots Classic Measles Exanthem

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