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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 1054-1057
Fever with rash: A rare complicated case of measles with thrombocytopenia


1 Classified Specialist (Dermatology), Classified Specialist (Medicine) and Commandant, Military Hospital, Ahmedabad, Gujarat, India
2 Senior Advisor (Medicine and Nuclear Medicine), Command Hospital, Pune, Maharashtra, India

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Date of Web Publication5-Oct-2017
 

   Abstract 


Background: Fever with rash is a diagnostic challenge for treating physician. Careful illustration of history, clinical examination and judicious investigations are essential for managing such case.
Case Report: A 35years old soldier, presented with intermittent high grade fever associated with dry cough, difficulty in swallowing, vomitings, watery loose stools and high coloured urine of seven days duration. Examination revealed temperature of 1030 F, tachycardia, pharyngeal suffusion, conjuctival congestion, petechial rash, distended mildly tender abdomen and decreased air entry in both the lung fields. The laboratory investigations revealed leucopenia, thrombocytopenia, mild shift to left with toxic granules, deranged LFT, Chest X-ray showing pulmonary oedema and IgM Ab for measles was positive. He was promptly managed with supportive therapy.
Conclusion: Measles with pulmonary oedema, features of SIRS, thrombocytopenia is very.

Keywords: Fever, measles, thrombocytopenia

How to cite this article:
Singh GK, Mahale M, Kumar P G, Sridhar B. Fever with rash: A rare complicated case of measles with thrombocytopenia. Ann Trop Med Public Health 2017;10:1054-7

How to cite this URL:
Singh GK, Mahale M, Kumar P G, Sridhar B. Fever with rash: A rare complicated case of measles with thrombocytopenia. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Oct 13];10:1054-7. Available from: http://www.atmph.org/text.asp?2017/10/4/1054/215891



   Introduction Top


Fever with rash with deteriorating clinical state is not only worrisome for patients, but also equally challenging for treating physicians. There are wide varieties of infectious and noninfectious causes which can present with fever with rash. Diagnosing them early and successfully treating them is a gratifying task. One such case is measles which is a highly contagious, serious disease caused by a paramyxovirus virus. The disease remains one of the leading causes of death among young children globally, despite the availability of a safe and effective vaccine. Approximately 114,900 people died from measles in 2014 – mostly children under the age of 5.[1]

Complications with measles are relatively common, ranging from mild complications such as diarrhea to serious complications such as pneumonia (either direct viral pneumonia or secondary bacterial pneumonia), bronchitis (either direct viral bronchitis or secondary bacterial bronchitis), otitis media,[2] acute brain inflammation [3] (and very rarely–subacute sclerosing panencephalitis [SSPE]),[4] and corneal ulceration (leading to corneal scarring).[5] Complications are usually more severe in adults who catch the virus.[6]

Thrombocytopenia with measles has hardly been reported in literature. A middle-aged soldier who presented with fever with rash with rapidly deteriorating course developed pulmonary edema, features of systemic inflammatory response syndrome; thrombocytopenia was successfully managed by early diagnosis and prompt management. This case is being presented for rarity and successful outcome.


   Case Report Top


A 35-year-old serving soldier, with no known medical comorbidities in the past, immunized appropriately for age, had a history of travel to native place 20 days back, presented with a history of fever for 7 days and rash of 4 days' duration. Fever was intermittent with chills and rigor, associated with nonproductive dry cough with difficulty in swallowing and multiple episodes of vomits and watery loose stools with high-colored urine. He had redness and watering from the eyes. The rash started from the face and spread all over the body in the next 48 h. There was a history of consumption of some medicines at the native place after 3 days of onset of fever. There was no history of altered sensorium, hematemesis, melena, oliguria, arthritis or contact with animals, and high-risk behavior.

The initial general examination revealed sick-looking febrile patient with temperature of 103°F, heart rate of 110/min, respiratory rate of 28/min, desaturation of 88% at room air, and 96% on oxygenation. There was severe pharyngeal suffusion and moderate conjunctival congestion with subconjunctival hemorrhage. Dermatological examination revealed, predominantly macular blanching erythema, scattered erythematous macules with islands of sparing, involving face, trunk, and all extremities sparing palms, soles, lips, and genitalia. The ENT and oral examination revealed thick greenish-colored mucoid secretion in the naso-oropharynx with multiple aphthous-like ulcer on the pharynx. Buccal mucosa and tonsils appeared normal. The Nikolsky sign was negative. There was no significant lymph node enlargement and no overt bleeding manifestations.

Systemic examination revealed distended abdomen with generalized tenderness, increased bowel sound with no guarding or rigidity. Chest examination revealed decreased air entry bilaterally with conducted sounds and fine crepitations around the right scapular area. Cardiovascular examination revealed tachycardia with no murmur. Central nervous system examination was normal with no neck rigidity.

On the subsequent day, he had rapid progression of the rash with facial edema and appearance of flat purpuric lesions mainly on the back and flanks [Figure 1] and [Figure 2] with positive Hess capillary test. Based on the history and available clinical examination, the presumptive diagnosis of complicated viral exanthematous fever was made. A differential diagnosis of dengue hemorrhagic fever, cutaneous adverse drug reaction, complicated malaria, complicated enteric fever, and H1N1 infection was considered.
Figure 1: Purpuric lesions on the back of the patient

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Figure 2: Purpuric lesions on the flank of the patient

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Laboratory investigations revealed hemoglobin of 12.7 g%, total leukocyte count of 3800/cmm, and platelets of 61,000/cmm. Peripheral blood smear and paracheck for malarial parasite were negative, but there was a shift to the left with toxic granules. Liver function test was deranged with bilirubin 4.4 mg/dl, conjugated 3.8 mg/dl with serum glutamic-oxaloacetic transaminase/serum glutamic pyruvic transaminase/alkaline phosphatase of 116/148/370 IU/L. Renal function test, serum electrolytes and prothrombin time, partial thromboplastin time with kaolin, and international normalized ratio were normal. Urine examination revealed proteinuria with positive bile pigments. Dengue serology including, IgM and ELISA tests, was negative. Stool examination revealed greenish, semi-solid stool containing blood. Hepatitis B surface antigen, anti-hepatitis C virus, HIV, H1N1 serology, IgM for leptospirosis, ASO titer, and Widal titer were unremarkable. Chest X-ray finding revealed bilateral asymmetric perihilar airspace opacities with peripheral sparing suggestive of pulmonary edema. At the periphery, there were patchy heterogeneous opacities suggestive of patchy lobular consolidation [Figure 3]. Ultrasonography abdomen revealed mild hepatomegaly. The blood culture, urine culture, and throat swab culture did not grow any organisms. The IgM antibody for measles by ELISA was 17.22 NTU (normal: 9–11 NTU). Virus identification and viral culture could not be performed due to lack of facility. Meanwhile, details of drug revealed to be tablet paracetamol and tablet pantoprazole which were unlikely to cause such symptoms.
Figure 3: Chest X-ray posteroanterior view showing bilateral asymmetric perihilar airspace opacities with peripheral sparing suggestive of pulmonary edema

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He was diagnosed as a case of complicated measles with thrombocytopenia and was treated with high-calorie and protein-rich diet, intravenous (IV) fluids, broad-spectrum antibiotics, Vitamin A supplements, and supportive topical emollient and care of eyes. In hospital, the patient became afebrile with return of well-being, disappearance of rash, and normalization of the laboratory reports and chest X-ray [Figure 4] over another 10 days.
Figure 4: Resolution of pulmonary edema

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   Discussion Top


Fever with rash opens up Pandora's box in front of treating physicians, mimicking, multiple differential diagnoses. However, diligent history taking, detailed clinical examination, and high index of suspicion may lead to correct diagnosis and early recovery from the disease. This case had very rapid deteriorating course; timely diagnosis because of prodromal features, nature of rash, and supported by IgM positivity of measles resulted in early effective management with complete recovery. There are a number of studies which discussed thrombocytopenia following measles, mumps, and rubella vaccination,[7],[8],[9] but complicated measles with thrombocytopenia is a rarity. This case has clinical features mimicking dengue fever; however, the repeated dengue serology tests including ELISA tests were negative.

Our case must have had atypical measles as he was already vaccinated for measles in early childhood. The Centers for Disease Control and Prevention America defines “atypical measles” which occurs only in persons who received inactivated (killed) measles vaccine (KMV) and are subsequently exposed to wild-type measles virus. KMV sensitizes the recipient to measles virus antigens without providing protection. Subsequent infection with measles virus leads to signs of hypersensitivity polyserositis. The illness is characterized by fever, pneumonia, pleural effusions, and edema. The rash is usually maculopapular, but may have urticarial, purpuric, or vesicular components.[10]

He was managed by supportive therapy. Broad-spectrum antibiotics in the form of third-generation cephalosporin and fluoroquinolones, IV fluids, antipyretics, paracetamol, Vitamin A supplement, and care of eyes and skin by specialists allowed recovery of the patient in short time frame in spite of deranged biochemical and serological parameters. He has been advised to get revaccination done with live vaccine of measles and to be on follow-up considering any delayed complication such as “SSPE” which may develop 7–10 years after a person has measles, even though the person seems to have fully recovered from the illness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. Measles Deaths Reach Record Lows with Fragile Gains Toward Global Elimination; 2015. Available from: http://www.who.int/mediacentre/news/notes/2014/measles2014206/en/. [Last updated on 2015 Aug 03; Last cited on 2014 Feb 06].  Back to cited text no. 1
    
2.
Gardiner WT. Otitis media in measles. J Laryngol Otol 2007;39:614-7.  Back to cited text no. 2
    
3.
Fisher DL, Defres S, Solomon T. Measles-induced encephalitis. QJM 2015;108:177-82.  Back to cited text no. 3
[PUBMED]    
4.
Anlar B. Subacute sclerosing panencephalitis and chronic viral encephalitis. Handb Clin Neurol 2013;112:1183-9.  Back to cited text no. 4
[PUBMED]    
5.
Semba RD, Bloem MW. Measles blindness. Surv Ophthalmol 2004;49:243-55.  Back to cited text no. 5
[PUBMED]    
6.
Sabella C. Measles: Not just a childhood rash. Cleve Clin J Med 2010;77:207-13.  Back to cited text no. 6
[PUBMED]    
7.
Beeler J, Varricchio F, Wise R. Thrombocytopenia after immunization with measles vaccines: Review of the vaccine adverse events reporting system (1990 to 1994). Pediatr Infect Dis J 1996;15:88-90.  Back to cited text no. 7
[PUBMED]    
8.
France EK, Glanz J, Xu S, Hambidge S, Yamasaki K, Black SB, et al. Risk of immune thrombocytopenic purpura after measles-mumps-rubella immunization in children. Pediatrics 2008;121:e687-92.  Back to cited text no. 8
[PUBMED]    
9.
Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic purpura after measles-mumps-rubella vaccination: A systematic review of the literature and guidance for management. J Pediatr 2010;156:623-8.  Back to cited text no. 9
[PUBMED]    
10.
Pink Book – Measles – Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf. [Last updated on 2016 Dec 30].  Back to cited text no. 10
    

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Correspondence Address:
Gautam Kumar Singh
Military Hospital, Ahmedabad - 380 003, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_526_16

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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