A 40-year-old man comes to the emergency department and reports, "I think I have pinkeye." He was feeling well until 4 days ago when he developed fever, malaise, rhinorrhea, and a dry cough. He then noticed bilateral eye redness, irritation, and mucoid drainage. A red rash formed on his neck and trunk yesterday morning and spread to his face by the evening. The patient has no ill family members but recently returned from a missionary trip to Bangladesh. He is up to date on his vaccinations.
Temperature is 39 C (102.2 F), blood pressure is 122/76 mm Hg, pulse is 90/min, and respirations are 16/min. Examination shows conjunctival erythema and edema. Small white papules are present on the buccal mucosa. Chest is clear to auscultation. Skin examination shows an erythematous, maculopapular rash that blanches on palpation, as shown in the exhibit.
Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient's illness?

Question

A 40-year-old man comes to the emergency department and reports, "I think I have pinkeye."  He was feeling well until 4 days ago when he developed fever, malaise, rhinorrhea, and a dry cough.  He then noticed bilateral eye redness, irritation, and mucoid drainage.  A red rash formed on his neck and trunk yesterday morning and spread to his face by the evening.  The patient has no ill family members but recently returned from a missionary trip to Bangladesh.  He is up to date on his vaccinations.
Temperature is 39 C (102.2 F), blood pressure is 122/76 mm Hg, pulse is 90/min, and respirations are 16/min.  Examination shows conjunctival erythema and edema.  Small white papules are present on the buccal mucosa.  Chest is clear to auscultation.  Skin examination shows an erythematous, maculopapular rash that blanches on palpation, as shown in the exhibit. 
Laboratory results are as follows:
 Which of the following is the most appropriate next step in management of this patient's illness?

Quizplus · Accepted Answer

11ec193a_964f_ea9a_853d_a1ab00150acb_MD0002_00 This patient who recently traveled to Bangladesh likely has measles. Measles is rare in the United States due to widespread vaccination efforts, but sporadic cases and outbreaks have been linked to travelers returning from endemic regions. Most cases arise in unvaccinated individuals as a single dose of the measles-mumps-rubella (MMR) vaccine is 93% protective and 2 doses (full vaccination) are 97% protective. However, vaccinated individuals can rarely develop the disease due to vaccine failure or waned immunity. Patients with measles infection usually pass through the following stages: Prodrome: Fever, malaise, and anorexia followed by the "3 Cs" of cough, conjunctivitis, and coryza. Koplik spots, small white-grey-blue lesions on an erythematous base, frequently form on the buccal and/or labial mucosa.Exanthem: Begins 2-4 days after fever onset and is characterized by an erythematous, macular, blanching rash that usually starts on the face and spreads in a cephalocaudal and centrifugal manner.Recovery: Clinical improvement usually begins within 48 hours of rash onset. However, complications, including diarrhea, immunosuppression with severe secondary infection, pneumonia, and/or neurologic disease (eg, encephalitis, subacute sclerosing panencephalitis), arise in up to 30% of cases. Prodrome: Fever, malaise, and anorexia followed by the "3 Cs" of cough, conjunctivitis, and coryza. Koplik spots, small white-grey-blue lesions on an erythematous base, frequently form on the buccal and/or labial mucosa. Prodrome: Fever, malaise, and anorexia followed by the "3 Cs" of cough, conjunctivitis, and coryza. Koplik spots, small white-grey-blue lesions on an erythematous base, frequently form on the buccal and/or labial mucosa. Exanthem: Begins 2-4 days after fever onset and is characterized by an erythematous, macular, blanching rash that usually starts on the face and spreads in a cephalocaudal and centrifugal manner. Exanthem: Begins 2-4 days after fever onset and is characterized by an erythematous, macular, blanching rash that usually starts on the face and spreads in a cephalocaudal and centrifugal manner. Recovery: Clinical improvement usually begins within 48 hours of rash onset. However, complications, including diarrhea, immunosuppression with severe secondary infection, pneumonia, and/or neurologic disease (eg, encephalitis, subacute sclerosing panencephalitis), arise in up to 30% of cases. Recovery: Clinical improvement usually begins within 48 hours of rash onset. However, complications, including diarrhea, immunosuppression with severe secondary infection, pneumonia, and/or neurologic disease (eg, encephalitis, subacute sclerosing panencephalitis), arise in up to 30% of cases. Patients with suspected measles infections require serum and throat/nasopharyngeal swab testing for measles IgM or RT-PCR. Treatment is largely supportive as no antiviral therapy is currently available. Measles is transmitted by droplet nuclei (which can remain suspended in the air for up to 2 hours) so airborne isolation is required for at least 4 days after rash onset; close contacts should be advised to wear masks or respirators. (Choice B) Cerebrospinal fluid analysis would be indicated for potential meningococcal infection, which typically presents within 24 hours (not 4 days) of symptom onset with fever, malaise, myalgias, headache, meningeal signs, and/or hemodynamic instability. Rash can occur but is typically petechial (nonblanching). (Choice C) Mononucleosis can cause fever, malaise, and maculopapular rash (usually after the administration of amoxicillin). However, most cases are also marked by tonsillitis/pharyngitis and cervical lymphadenopathy. Coryza, conjunctivitis, and white buccal lesions make measles more likely. (Choice D) Malaria often causes paroxysmal fever, nonspecific symptoms, and splenomegaly. Conjunctivitis, coryza, Koplik spots, and a maculopapular rash are not typical features. (Choice E) Doxycycline can be used to treat Rocky Mountain spotted fever, a tickborne illness that initially causes fever and nonspecific symptoms. Rash typically forms on day 3-5 and is blanching and erythematous, becomes petechial over time, and moves in a centripetal direction (starts on the wrists and ankles and moves centrally). This patient with a central rash and Koplik spots is more likely to have measles. Educational objective: Measles infections tend to begin with fever, malaise, and anorexia followed by the "3 Cs" of cough, conjunctivitis, and coryza. Koplik spots (white lesions on an erythematous base) then form on mucous membranes, followed by the characteristic exanthem (maculopapular rash that spreads in a cephalocaudal and centrifugal manner). Measles is highly infectious and transmitted by droplet nuclei, so airborne isolation is required for ?4 days after rash onset. __________ References: Measles: not just a childhood rash. (http://www.ncbi.nlm.nih.gov/pubmed/20200172)

A 40-Year-Old Man Comes to the Emergency Department and Reports