A 9-year-old black female, a recent emigree from Haiti, came to the Emergency Room because of a fever, headache, sore throat and mild cough. Her parents say that she has been sick for 2-3 days. You note that she has a runny nose and a mild conjunctivitis. Her temperature is 39, pulse rate 110 beats/min, blood pressure 90/60 mm Hg, and respiratory rate 42/min. You note that her pharynx is very red and that she also has some bright red spots with white centers on her buccal mucosa. Her chest is clear. You take a throat swab and send the child home instructing the parents to return with the child tomorrow when you will have the results of the throat culture.
Question 1 - Single Best Answer
The throat swab is most commonly used to diagnose?
A) whooping cough
B) influenza
C) strep throat
D) measles
E) diphtheria
Question 2 - Single Best Answer
On the whole, would you agree with the decision to send this child home with no treatment or instructions for care?
A) Yes, because even if she had a strep throat, tomorrow is soon enough to start treatment and viral diseases can't be cured
B) No, because she may not come back and miss treatment for a disease that could result in rheumatic fever
C) No, because she had a highly communicable disease that you should have recognized.
D) Both B and C have some merit
There are no beta hemolytic colonies seen on the blood agar plate the next day. The child does return and when you examine her again you notice a rash behind her ears and on her face. Careful examination of the rash shows that it is maculopapular.
Question 3 - Single Best Answer
The absence of beta hemolytic colonies on the blood agar plate means?
A) the child does not have scarlet fever
B) the child does not have rheumatic fever
C) the child does not have Rocky Mt. Spotted fever
D) the child has measles
E) the child has German measles
Question 4 - Single Best Answer
The differential diagnosis for a child with a rash is quite large. Measles, German measles and Rocky Mt. spotted fever should be considered. What are some other agents that can cause a rash?
A) B19, HHV3, Bordetella
B) chlamydia, Coxsackievirus, EEEV
C) hantavirus, flu virus, HHV3
D) Treponema pallidum, B19, Coxsackievirus
A good differential diagnosis for this child's disease would be measles, German measles, Rocky Mt. spotted fever, fifth disease, Coxsackievirus infection, secondary syphilis. You know its not scarlet fever because of the throat culture. A few parasitic diseases, that a recent emigrŽ could have, also have rashes.
Question 5 - Single Best Answer
You ask the parents if they have seen any ticks on the child or if she had been anywhere that she could have been bitten by a tick. This would bear on the diagnosis of which of the following?
A) measles
B) secondary syphilis
C) fifth disease
D) Rocky Mt. spotted fever
E) Coxsackievirus infection
Question 6 - Single Best Answer
What in the world causes fifth disease?
A) an adenovirus
B) a parvovirus
C) a poxvirus
D) a herpesvirus
E) a picornavirus
Question 7 - Single Best Answer
B19 usually causes a very mild disease. Two groups of people for whom it can be more serious, however, are?
A) teenagers and pregnant women
B) pregnant women and sickle-cell anemics
C) alcoholics and asplenics
D) smokers and alcoholics
E) the sexually promiscuous and drug addicts
Question 8 - Single Best Answer
What should have alerted you to the possibility of measles?
A) the conjunctivitis
B) the Koplik spots
C) the runny nose (coryza)
D) the cough
E) all of the above
Question 9 - Single Best Answer
How is measles normally prevented?
A) DPT vaccine
B) MMR vaccine
C) killed viral vaccine
D) oral vaccine
E) prophylactic antibiotics
Question 10 - Single Best Answer
When is the MMR vaccine usually given?
A) 2, 4, 6, 15 months and 4-6 years.
B) 2, 4, 15 months and 4-6 years.
C) 2, 4, 6, 15 months
D) 15 months and 11-12 years
Question 11 - Single Best Answer
Why is the MMR vaccine given so much later than the other childhood vaccines?
A) the live viruses are dangerous until the children have some natural immunity
B) the vaccines don't work due to maternal antibody before this time
C) the immune system is not mature enough to make antibodies before this time
D) cellular immunity that is needed will not develop before this time
Question 12 - Single Best Answer
What is/are the complication(s) of measles?
A) encephalitis
B) viral pneumonia
C) bacterial pneumonia
D) SSPE
E) all of the above
Question 13 - Single Best Answer
How can measles be confirmed?
A) heterophile antibodies
B) anti-measles IgG
C) anti-measles IgM
D) growth of the virus in tissue culture
E) all of the above
A measles antigen detection test, that the clinical laboratory recently introduced because of the high incidence of measles among immigrants, tested positive for the measles virus. You send the child home but tell the parents to keep her isolated and quiet. Eight other children and four adults in the same house were given measles vaccine. One baby was given hyperimmune serum globulin. Twenty neighborhood children that had never been immunized were also immunized.
Question 14 - Single Best Answer
How is it that so many of this child's contacts were not vaccinated?
A) the vaccine is only available in the USA and all the others were immigrants
B) the vaccine is optional and only purchased by the very rich
C) the lowest socioeconomic classes have the poorest vaccination rates
D) the perceived high incidence of reactions to the vaccine make it very unpopular
The sick child appeared to be recovering but after 10 days had a resurgence of fever, severe headaches, and seizures.
Question 15 - Single Best Answer
This new development?
A) is normal in the course of measles
B) signals measles pneumonia
C) occurs in about 0.1% of measles cases
D) is most likely unrelated to the measles
E) is SSPE
The child was hospitalized and given supportive care. Although many children suffer neurological deficits after measles encephalitis, this child recovered and was left with no sequelae.