A case history

 

Julie, a nine-year-old girl from Gorey, Co Wexford was brought by her mother to her GP with a red rash and a slight temperature. She had developed the rash the previous day and had complained of feeling tired and not wanting to eat. Julie's mother was concerned that her child might have measles.

Dr Peter Harrington, one of the GPs in a group practice in the town, found that Julie had an extensive rash over her upper body. Her tonsils were also enlarged and he confirmed that her temperature was elevated.

"When a child presents with a fever and a rash like Julie's, my first thought is that this represents an infection," Dr Harrington says. "In terms of a specific diagnosis, I would consider the possibility of rubella (German measles), measles, a streptococcal infection or one of the many non-specific viral infections of childhood."

At one time, Dr Harrington and the family doctors would not necessarily pursue further investigations but would monitor and treat the child symptomatically. "I now ask the Mum's consent to take blood to test for evidence of measles or rubella infection," Dr Harrington says. Why has he changed his practice?

"I think it is important to be able to feedback an exact diagnosis to parents. In Julie's case, the diagnosis was indeed one of non-specific viral infection, but they appreciated being told for definite that it wasn't measles or rubella."

Since the introduction of MMR vaccination, the number of positive tests for measles, mumps and rubella has dropped. However, when a test is positive, Dr Harrington will immediately notify the local medical officer for health in the South Eastern Health Board. With the present worry about a measles epidemic, he will telephone the community care doctors if he picks up a case of measles, as the health board may want to target, for example, a creche or playschool group attended by the infected child. A written communicable disease report is made for every case of measles, mumps or rubella.

Does knowing the exact diagnosis really make a difference? Dr Harrington, who is the ICGP representative on the NDSC disease notification sub-committee, believes it does. "If a patient is confirmed as having rubella infection, then I would advise time off work or school in order to help prevent further spread. Knowing that there is one case in your practice heightens your level of suspicion that other patients with a rash may also have the same disease. It also focuses you on the vaccine status of the patient - might they have missed MMR vaccination? A definite diagnosis will also focus your questioning in terms of recent contacts and you can give definite advice to the patient or the parents about avoiding contact with women in early or late pregnancy, for whom rubella in particular, would be a risk."

Meanwhile, Julie has made a full recovery after a few days treatment with fluids, rest and paracetamol syrup.