A 16-year-old girl is brought to the emergency department due to rash and joint pain. Yesterday, a pink rash developed on the patient's face and has spread to her chest, back, and extremities this morning. She awoke today with pain in her fingers and wrists as well. The patient feels tired and has had a fever but no neck stiffness, nausea, or vomiting. She is sexually active with a male partner and uses condoms inconsistently. The patient has received no vaccinations. Temperature is 38.2 C (100.8 F), blood pressure is 118/76 mm Hg, pulse is 86/min, and respirations are 14/min. Physical examination shows a well-appearing and well-hydrated girl. There is a blanching, erythematous maculopapular rash on the face, chest, back, and extremities that spares the palms and soles. Posterior auricular and suboccipital lymphadenopathy is present. The oropharynx is clear. Which of the following is the most likely cause of this patient's symptoms?

Question

A 16-year-old girl is brought to the emergency department due to rash and joint pain.  Yesterday, a pink rash developed on the patient's face and has spread to her chest, back, and extremities this morning.  She awoke today with pain in her fingers and wrists as well.  The patient feels tired and has had a fever but no neck stiffness, nausea, or vomiting.  She is sexually active with a male partner and uses condoms inconsistently.  The patient has received no vaccinations.  Temperature is 38.2 C (100.8 F), blood pressure is 118/76 mm Hg, pulse is 86/min, and respirations are 14/min.  Physical examination shows a well-appearing and well-hydrated girl.  There is a blanching, erythematous maculopapular rash on the face, chest, back, and extremities that spares the palms and soles.  Posterior auricular and suboccipital lymphadenopathy is present.  The oropharynx is clear.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d6ce_655e_bc81_577262c1f8af_MD0003_00 This unimmunized patient has a rash with cephalocaudal spread, localized lymphadenopathy, and arthralgias, findings consistent with rubella infection. Rubella is no longer endemic in the United States due to widespread vaccination, but sporadic or imported cases do occur. Rubella may be asymptomatic or present in well-appearing patients as a mild illness that begins with low-grade fever and lymphadenopathy (particularly posterior cervical, posterior auricular, and suboccipital). A blanching, fine, pink maculopapular rash erupts on the face and spreads cephalocaudally within 24 hours, sparing the palms and soles. Adolescents and adults, particularly females, may have arthralgia and/or arthritis at the time of rash development. Although most symptoms resolve in a few days, joint pain can last up to a month. In contrast to the uncomplicated course seen in most children and adults, prenatal infection (particularly in the first trimester) can cause miscarriage, stillbirth, or congenital rubella syndrome. Therefore, vaccination with the live, attenuated measles, mumps, and rubella vaccine is recommended to prevent community spread of infection. (Choice A) Fever and posterior cervical lymphadenopathy are features of infectious mononucleosis due to Epstein-Barr virus, but exudative pharyngitis is typically the most prominent manifestation. In addition, a maculopapular rash is less common unless there is a history of beta-lactam antibiotic administration. (Choice B) Although measles causes a rash with cephalocaudal spread, it classically presents with high fever (≥40 C [≥104 F]) and a prodrome of cough, coryza, and conjunctivitis. Patients are ill-appearing, unlike this girl, and arthralgia is not seen in measles. measles (Choice C) Disseminated gonococcal infection (ie, Neisseria gonorrhoeae) can present with rash, fever, and polyarthralgia in a sexually active patient. However, the rash of disseminated gonococcus is usually vesiculopustular and rarely involves the face. (Choice E) Secondary syphilis (ie, Treponema pallidum) usually presents with fever and a maculopapular rash involving the trunk and extremities. The rash of syphilis includes the palms and soles, which are spared in this patient. (Choice F) The rash of varicella-zoster virus (ie, chickenpox) is characterized by intensely pruritic, vesicular lesions that appear in successive crops, and crust over after several days. This patient has a maculopapular, nonpruritic rash. Educational objective: Rubella is a mild illness that presents with low-grade fever, a maculopapular rash with cephalocaudal spread, and posterior auricular and suboccipital lymphadenopathy. Adolescents and adults, especially females, may also have arthralgia and/or arthritis that can persist after the rash resolves. References: Rubella. (http://www.ncbi.nlm.nih.gov/pubmed/25576992) Common childhood viral infections. (http://www.ncbi.nlm.nih.gov/pubmed/25703483)

A 16-Year-Old Girl Is Brought to the Emergency Department Due