A 10-month-old girl is brought to the office due to a rash. The patient has had a low-grade fever for the past 3 days that has been controlled with acetaminophen. A rash developed on her face 2 days ago and has since spread to her chest, abdomen, and extremities. The patient has had no cough, rhinorrhea, nasal congestion, vomiting, or diarrhea. She has otherwise been healthy. The patient has received all routine, age-appropriate vaccinations and takes no medications. Temperature is 38 C (100.4 F), blood pressure is 100/50 mm Hg, pulse is 88/min, and respirations are 18/min. Physical examination shows a playful infant with small, tender lymph nodes in the suboccipital, posterior auricular, and posterior cervical areas. There is patchy erythema on the soft palate. The rash is shown in the image below. A similar-appearing rash is present on the face. The remainder of the examination is normal. Which of the following diagnoses is most consistent with this patient's presentation?

Question

A 10-month-old girl is brought to the office due to a rash.  The patient has had a low-grade fever for the past 3 days that has been controlled with acetaminophen.  A rash developed on her face 2 days ago and has since spread to her chest, abdomen, and extremities.  The patient has had no cough, rhinorrhea, nasal congestion, vomiting, or diarrhea.  She has otherwise been healthy.  The patient has received all routine, age-appropriate vaccinations and takes no medications.  Temperature is 38 C (100.4 F), blood pressure is 100/50 mm Hg, pulse is 88/min, and respirations are 18/min.  Physical examination shows a playful infant with small, tender lymph nodes in the suboccipital, posterior auricular, and posterior cervical areas.  There is patchy erythema on the soft palate.  The rash is shown in the image below.  A similar-appearing rash is present on the face.   The remainder of the examination is normal.  Which of the following diagnoses is most consistent with this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d601_ed0f_bc81_f9acb41bfd27_MD0003_00 This playful and well-appearing infant has fever, rash, and lymphadenopathy, findings that can be seen with rubella infection. Rubella is a mild viral illness that children are typically immunized against at age 12 months and age 4 years with the live measles, mumps, and rubella vaccine; this 10-month-old patient's age-appropriate vaccinations would not include protection against rubella. Symptoms of rubella develop 2-3 weeks after inhalation of infected respiratory droplets. Patients may be asymptomatic or have initial symptoms of low-grade fever and lymphadenopathy, particularly suboccipital, posterior auricular, and posterior cervical. A fine, pink, maculopapular exanthem begins on the face, spreads quickly in a cephalocaudal pattern to the rest of the body, and lasts <3 days. Some patients also have petechiae or erythematous papules, known as Forchheimer spots, on the soft palate. Treatment is supportive. Although postnatal infection (as in this patient) is mild, prenatal infection can result in spontaneous abortion, fetal demise, or congenital rubella syndrome. (Choice A) Erythema infectiosum is caused by parvovirus B19 and classically presents in school-aged children with prodromal symptoms (eg, fever, rhinorrhea) followed by a "slapped cheek" rash and a lacy or reticular rash on the body. The rash typically does not appear until prodromal symptoms have resolved. In addition, palatal lesions and posterior auricular and suboccipital lymphadenopathy are not typical. "slapped cheek" rash (Choice B) Patients with Kawasaki disease (KD) have fever for ≥5 days with 4 of the following: conjunctivitis, mucositis, rash, extremity edema, and lymphadenopathy (node >1.5 cm). This patient has had only a rash and fever for 3 days, making KD less likely. Kawasaki disease (KD) (Choice C) Measles causes a maculopapular rash that spreads cephalocaudally and, after a few days, coalesces and darkens (eg, reddish-brown). Patients are ill-appearing with high fever up to 40 C (104 F), coryza, and cough, none of which are present in this patient. Measles (Choice E) Scarlet fever is a streptococcal infection that can cause fever, palatal petechiae, and a "sandpaper" texture rash. However, the rash usually begins and is most prominent along skinfolds (eg, axillae, groin) and then spreads to the trunk and extremities. In addition, the diagnosis is rare for patients under age 3. Educational objective: Rubella is a mild illness characterized by low-grade fever, lymphadenopathy (particularly suboccipital, posterior auricular, and posterior cervical), and a maculopapular exanthem that spreads cephalocaudally. Forchheimer spots (ie, erythematous papules on the soft palate) may be seen. References: Rubella. (http://www.ncbi.nlm.nih.gov/pubmed/25576992) Common childhood viral infections. (http://www.ncbi.nlm.nih.gov/pubmed/25703483)

A 10-Month-Old Girl Is Brought to the Office Due to a Rash