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Difficulty: MediumPediatric Infectious Diseases

A previously healthy 99-month-old female infant presents to an urgent care center with a five-day history of persistent high temperatures, a harsh barking-like cough, and a severely runny nose. Her parents note that she has been rubbing her excessively red, tearing eyes. The family recently moved from a rural region in a developing country, and the infant has not received any childhood immunizations. On triage, her temperature is 39.7∘C39.7^\circ\text{C} (103.5∘F103.5^\circ\text{F}), pulse is 158/min158\text{/min}, and respirations are 48/min48\text{/min}. Pulse oximetry is 96%96\% on room air. Examination of the oropharynx reveals tiny white lesions on the inner cheeks that resemble grains of salt on a red background. Additionally, a non-pruritic, erythematous, maculopapular exanthem is visible starting at the forehead and extending downward to the neck and upper shoulders. Auscultation of the chest demonstrates coarse breath sounds bilaterally without wheezing. Which of the following is the most appropriate next step in management?

  1. Administration of oral vitamin AAnswer
  2. B
    Administration of the measles, mumps, and rubella (MMR) vaccine
  3. C
    Initiation of oral amoxicillin therapy
  4. D
    Nebulized albuterol and oral dexamethasone
  5. E
    Intravenous administration of acyclovir

Answer

Administration of oral vitamin A
The correct answer is the administration of oral vitamin A. This patient's presentation is highly characteristic of measles (rubeola), featuring the classic prodrome of high fever, cough, coryza, and conjunctivitis. The presence of tiny white lesions on the buccal mucosa (Koplik spots) is pathognomonic for measles, and the subsequent appearance of a cephalocaudal maculopapular rash confirms the diagnosis. In addition to supportive care, the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommend the administration of vitamin A for children with severe measles, infants aged 66 to 2424 months, and those in areas with known vitamin A deficiency. Measles virus infection causes a significant depletion of vitamin A stores, which can lead to delayed recovery, blindness, and a higher risk of fatal complications such as secondary bacterial pneumonia. Vitamin A therapy has been proven to significantly reduce morbidity and mortality in these patients.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and physical examination findings.
The infant exhibits a high fever, the '3 Cs' (cough, coryza, conjunctivitis), pathognomonic Koplik spots (tiny white lesions on the buccal mucosa), and a characteristic cephalocaudal maculopapular rash.
Identifying this classic clinical prodrome and unique mucosal enanthem confirms the diagnosis of measles (rubeola).
2
Determine the most appropriate therapeutic intervention for an acute, severe measles infection.
In addition to isolation and supportive care, oral vitamin A administration is indicated.
Measles virus infection significantly depletes vitamin A stores. Supplementing vitamin A decreases the risk of severe complications such as pneumonia, diarrhea, and blindness (xerophthalmia), thereby reducing overall mortality in unimmunized infants.

Key Concept

The clinical diagnosis of measles relies on recognizing the prodrome of high fever, cough, coryza, and conjunctivitis, followed by pathognomonic Koplik spots and a cephalocaudal maculopapular rash. Treatment is largely supportive, but oral vitamin A must be administered to reduce severe morbidity and mortality.
Estimated Time:1m 15s
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Pediatric Infectious Diseases

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