ID Case Presentation
Michael Eskander, PGY-3
Dr. Lanny Hsieh
8/7/2014
HPI
 CC: “Flu-like symptoms”
 HPI: 45YO Hispanic male with multiple-day history of
generalized fatigue, malaise, and fatigue stating he cannot
even get out of bed.
 Then developed productive, non-bloody cough associated
with rhinorrhea and frontal sinus headaches.
 Associated with night sweats and subjective fevers at
home
 Weight loss of unquantifiable amount for a few months –
may be due to loss of appetite
HPI
 + left lateral neck pain. - HA
 No photo-/phonophobia, No blurry vision
 + profuse, watery, nonbloody diarrhea ~3x/day
 No sick contacts, recent travel, camping/tick bites
 - stiffness or tenderness of medium/large joints
 Also notes a rash that began on the top of his forehead and
appeared to have spread down his body involving his chest,
then abdomen and legs
 Significant desquamation of his bilateral palms and dorsum of feet
with associated swelling and tightness surrounding the digits.
 Believes that he received all his childhood vaccinations but has
not seen a physician and is unclear of whether he was able to
receive booster vaccinations.
History
 PMHx:
 Incarcerated from 2006-2013: at that time he was found to
be PPD positive and was treated for latent with likely
isoniazid x 6 months. Never had active TB.
 DM2 – on insulin
 HTN
 OUTPATIENT MEDS:
 Metformin 500 mg orally 2 times a day
 Lantus
 Regular insulin correctional scale
History
 Family History:
 Dad: HTN, DM. ESRD on HD
 Mom: HTN, DM
 Social History:
 Etoh: history of significant binge drinking 4-5 years.
currently social drinking. Quit 3 years ago.
 Tobacco: 1-2ppd x 20-30 years. currently smoking 1ppd.
 IVDU: denies.
 Living Status: Santa Ana with wife.
 Allergies:
 No Known Allergies
Physical
 Vital Signs:
 Tc: 37.5 HR: 100 BP: 119/60 RR: 32 SpO2: 92% on NC
Gen NAD. AAO x3
HEENT: EOMI PERRLA anicteric sclera. Multiple tender lymph
nodes in the posterior cervical chain. dry oral mucosal. no nuchal
rigidity.
CARD: RRR no m/r/g
PULM: CTAB no w/r/c
ABD: Soft NT/ND positive BS.
EXT: no c/c/e. 2+ distal pulses. Soft tissue swelling of the bilateral hands.
NEURO: CN II-XII intact. no focal motor or sensory deficits.
Skin:
 Multiple bright red punctate nonblanchable lesions overlying the
lateral aspect of the bi-lateral feet.
 Diffuse scaly erythema overlying the entire body.
 Desquamation of the bilateral palms with shortened ragged nails.
Labs
Lactate: 1.8
121 | 86 | 14
--------------------< 413 Ca: 9.2
5.5 | 26 | 1.2
WBC: 5.6 / Hb: 17.1 / Hct: 50.1 / Plt: 168
-- Diff: N:4.3% L:0.4% Mo:0.9% Eo:0.0% Baso:0.0%
Prot: 7.3 / Alb: 3.1 / Bili: 1.3 / AST: 63 / ALT: 164 / AlkPhos: 545
UA: >1000 Glucose, +Ketones, no other abnormalities
Imaging
Imaging
Imaging
Ddx
 Common cold
 Viral syndrome - Rhinovirus, parainfluenza, influenza,
adenovirus, RSV, parvovirus B19
 Dengue fever (travelers)
 Measles (Rubeola)
 VZV
 Scarlet fever
 Rickettsial infection (campers)
 Drug eruption
 HSP – IgA vasculitis
Hospital Course
ED: Vanc/Zosyn. IVF rehydration.
HOD #1:
- Vanc/Zosyn Stopped, Hyponatremia resolved
RSV, Influenza A+B: negative
Sputum AFB negative x2
HIV: Negative
TPA: Negative
C diff.: Negative
CK, Plasma: 25 IU/L
C Reactive Protein, Plasma: 7.4* MG/DL
Sedimentation Rate: 38 MM/HR
R. rickettsii IgG: Neg
R. rickettsii IgM: Neg
R. typhi IgG: Neg
R. typhi IgM: Neg
Quant. TB Gold: Neg
Hepatitis C IgG: Reactive
A1C: 14.4
Measles IgG: 2.58*
Measles IgM: >40 (>=20
positive)
Measles PCR positive
Measles
 Classical Manifestations:
 Incubation, Prodrome, Exanthem, Recovery
 Incubation – usually 8-10 days
 Prodrome – Fever, malaise, anorexia followed by
conjunctivitis, coryza, and cough
 Koplik’s spots: 1-3mm whitish, grayish, or bluish elevations
with erythematous base
 Exanthem – maculopapular, blanching rash beginning on
the face and spreading cephalocaudally and centrifugally
to involve the neck, upper trunk, lower trunk and
extremities
 Recovery – 48hrs following exanthem. Cough may persist.
Immunity occurs.
Measles
Koplik’s Spots
Classic Measles Exanthem
Thank You!