Case Studies

Case 19

A mother brought her 2-year-old child to the surgery complaining that the child had been irritable and had a temperature for the last 2 days. Clinical examination confirmed the temperature and the child was noted to have a runny nose and eyes. Additionally, she had a cough. There was no evidence of rash, and examination of the ears and chest revealed no abnormalities. Advice was given to the mother to use appropriate doses of paracetamol. The mother had one other child who was aged 5 and neither of her children had received their routine vaccinations because she was concerned about the "risks of side effects".

The on-call service was called that evening because the child had had a convulsion. The attending doctor noted a fine macular rash at the hairline and that the child’s temperature was 39 °C, and diagnosed a febrile convulsion.

• 1. What vaccines should a child of 2 years have received?

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  This differs from country to country but in the UK children should have been immunized against diphtheria, polio, pertussis, Haemophilus influenzae b, tetanus, meningitis C, Streptococcus pneumoniae, measles, mumps and rubella.

• 2. What is the significance of the febrile convulsions?

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  Parents are often fearful of convulsions. Although they can be a sign of severe underlying disease, more often their only significance is as an accompaniment to fever. The physician should reduce the temperature and investigate the cause of the fever.

• 3. From the clinical picture described, what do you think may be the diagnosis?

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  Coryza with a febrile convulsion and a fine macular rash at the hairline is a typical presentation of measles. It is notable that the child is unvaccinated.

• 4. How can the diagnosis be confirmed?

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  The simplest way to confirm the diagnosis would be to identify Koplik’s spots in the mouth of the child. This would make the clinical diagnosis

• 5. How could the diagnosis be confirmed by the laboratory?

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  Laboratories would wish to confirm the diagnosis because of the public health implications. This could be achieved by a saliva sample that could be examined for measles-specific IgM.

• 6. Are there any other actions necessary?

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  The contacts have to be considered. Measles is a very infectious condition so it may be necessary to contact the local Health Protection Unit to investigate spread in the community.