A 5-year-old boy is brought to the office for his annual well-child visit. The boy was briefly hospitalized a month ago for an asthma exacerbation, which was treated with albuterol and oral corticosteroids. He has been well since then except for a runny nose and cough for the past 2 days. He takes an inhaled corticosteroid daily and albuterol as needed, most recently 3 weeks ago. The patient lives at home with his mother, who is 38 weeks pregnant, and his father and 2-year-old sister. He recently started kindergarten and is doing well. Temperature is 36.7 C (98 F). The patient is tracking along the 40th and 60th percentiles for weight and height, respectively. Physical examination shows a well-appearing boy who speaks clearly in full sentences, counts to 12, and can hop on one foot. The lungs are clear to auscultation, and the remainder of the examination is unremarkable. He is scheduled to receive the second dose of measles-mumps-rubella (MMR) vaccine today. The parents say, "After his first MMR shot a few years ago, he had a fever up to 39.4 C (103 F), and we almost took him to the emergency department." Which of the following is the most appropriate next step in management of this patient?

Question

A 5-year-old boy is brought to the office for his annual well-child visit.  The boy was briefly hospitalized a month ago for an asthma exacerbation, which was treated with albuterol and oral corticosteroids.  He has been well since then except for a runny nose and cough for the past 2 days.  He takes an inhaled corticosteroid daily and albuterol as needed, most recently 3 weeks ago.  The patient lives at home with his mother, who is 38 weeks pregnant, and his father and 2-year-old sister.  He recently started kindergarten and is doing well.  Temperature is 36.7 C (98 F).  The patient is tracking along the 40th and 60th percentiles for weight and height, respectively.  Physical examination shows a well-appearing boy who speaks clearly in full sentences, counts to 12, and can hop on one foot.  The lungs are clear to auscultation, and the remainder of the examination is unremarkable.  He is scheduled to receive the second dose of measles-mumps-rubella (MMR) vaccine today.  The parents say, "After his first MMR shot a few years ago, he had a fever up to 39.4 C (103 F), and we almost took him to the emergency department."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bdde_d3a7_8f63_c986f262a842_MD0005_00 The measles-mumps-rubella (MMR) vaccine is a live-attenuated vaccine typically administered at ages 1 and 4. Common adverse effects include fever, rash, and transient lymphadenopathy. These adverse effects are not contraindications to receiving a subsequent MMR vaccine dose. Contraindications include anaphylaxis (eg, respiratory compromise, hypotension, angioedema) to neomycin or gelatin (which are components of the vaccine) or after prior administration of the MMR vaccine. Patients who are pregnant or attempting to become pregnant should also not receive the MMR vaccine due to the risk of congenital rubella syndrome in the fetus. Finally, immunodeficient patients, such as those who have HIV with CD4 <200/mm³, congenital immunodeficiency, or hematologic/solid tumors, should not receive the MMR vaccination due to the risk of life-threatening disseminated infection from the attenuated virus. Household contacts of these patients, including children of pregnant women, can safely receive live vaccines (Choice D). (Choice A) Administering antipyretics (eg, acetaminophen) prior to vaccination has not been shown to prevent high fever and could decrease immunogenicity. (Choice C) The MMR vaccine does not contain a significant amount of egg protein, and a history of egg allergy is not a contraindication to administration. The yellow fever vaccine is contraindicated in patients with egg allergy. (Choice E) Mild illness (eg, acute otitis media, upper respiratory infection) is not a contraindication for administering vaccines. Delay of vaccination increases time of potential exposure to vaccine-preventable disease. This child is afebrile, has a normal physical examination, and should be given the MMR vaccine. Educational objective: Measles-mumps-rubella (MMR) vaccination is contraindicated in patients with anaphylaxis to prior MMR vaccination, anaphylaxis to neomycin or gelatin, severe immunodeficiency, or pregnancy. It can be given to patients who had fever after prior vaccination and to those who are household contacts of immunodeficient or pregnant individuals. References: Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). (http://www.ncbi.nlm.nih.gov/pubmed/23760231)

A 5-Year-Old Boy Is Brought to the Office for His