Even classic presentations of common illness can be crowded out of your differential, during a public health outbreak emergency.
The electronic alert fired at triage: fever and rash and overseas travel. Mask the patient. Airborne isolation. Assess for measles. Call Infection Prevention.
The patient, a man* in his early 40s, had been worried about it, too. He saw the news about New York City’s public health emergency. He got vaccinated as a child and he didn’t live in one of the high-risk ZIP codes, but who knows? In the subway, on the sidewalks, you cross paths with a lot of people. His extended family included a newborn and he wanted to be sure.
I met him in the isolation room and began to take a history, between phone calls from Infection Prevention and hospital administration. Was anyone else in the waiting room before he was masked at triage? How soon can you send titers? What’s the vaccination status of the visitors that are with him?
He had just gotten off a plane home, from his Mexico vacation. At this point, five days after the rash had started, he didn’t look like he had measles – though in the early stages, it sort of did. His phone’s camera roll showed the evolution from flat red subcentimeter spots around the face and neck to a whole-body, non-blanching, coalescelent maculopapular rash.
Also reassuringly, he had had the rash for five days – classically, measles isn’t contagious after four days of rash. I joked with the charge nurse that we could safely discontinue the negative pressure isolation (she didn’t find it amusing).
So, the story didn’t perfectly fit measles – but no one was willing to lower their guard just yet, which would expose patients and staff.
We’d all heard the story from a few weeks prior, about an infant from overseas that presented to another NYC ED, with fever and diarrhea. She was treated, released and returned a few days later with a rash. The case had nothing to do with the anti-vax zealots who’ve caused the current crisis – this infant just hadn’t received the MMR vaccine, and had been traveling from a country where measles was still a risk. A case like this could have presented at any time in a city like New York, but happened to occur during the worse outbreak in decades.
By the time that infant was isolated, a lot of patients, visitors and staff (across two ED visits) had been exposed to measles. They all had to be contacted and cautioned to quarantine themselves, and noteworthy symptoms. Alerts were built into the EMR so that if any of these exposed patients showed up during the measles incubation period, staff could be warned and spring into action.
Across the city, informaticists like me were working with DOH and EMR analysts to build other alerts. For instance, patients hailing from high-risk ZIP codes in Williamsburg and Rockland County, regardless of chief complaint, were to be quizzed on measles exposure and vaccination status at triage. We also adapted our old Ebola alerts for measles, liberalizing the triggers to include fever or rash and any overseas travel. That’s the alert that fired at triage for our patient – the new system was working. Infection Prevention and hospital administration were notified and following the case. We were determined to see it through, without exposing anyone.
But as measles fell further down the differential, a plausible alternative was sought. The patient had been in his usual good state of health until about two weeks prior. A dentist had worked on his right lower molar, and he had developed some swelling and a sore throat within a day or two – so the dentist prescribed amoxicillin. The swelling slowly improved. Then, five days ago, he felt a fever and noticed a rash around the right lower jaw. He took some ibuprofen and proceeded to fly to the Mexico, where he had planned a five-day vacation. Unfortunately, by the time he landed, the fever had persisted, and the rash had spread.
He saw a doctor in the island’s clinic who saw the rash, felt the fever, learned the patient was from New York, and expressed concern for measles. The poor guy isolated himself in his hotel room throughout the vacation, as the rash spread. He never had Koplik spots. The fever abated before the flight home, but new lymphadenopathy appeared in his left inguinal crease.
Chest X-ray and urinalysis were unremarkable. Blood work was coming back – normal CBC and electrolytes, mild transaminitis. HIV testing came back negative. GC was negative, too (that inguinal lymphadenopathy was causing some head-scratching). Flu and RSV and strep testing came back negative as well.
After much discussion with Infection Prevention, and much to the patient’s consternation, we decided not to test for measles. There was a disruptive aspect to sending samples to the DOH – we would probably have to log the name and contact info for all the patient visitors in the ED at the time of the patient’s arrival) and commit to monitoring these potentially exposed individuals, at least for the day or so before test results were available.
But most importantly, we soon had another explanation for the patient’s presentation: the monospot test came back positive. The patient had acute infectious mononucleosis from Epstein-Barr virus. This explained the initial sore throat and cervical lymphadenopathy – the dental work was just a red herring. The transaminitis was not uncommon, either. The amoxicillin prescription triggered the classic, but still poorly understood, “ampicillin rash.”
We cautioned the patient to avoid contact sports (splenic injury precautions) and reassured him that his rash would subside in the coming days. As for infectivity, salivary secretions would be a risk for infecting others, for at least another month, but we could safely discontinue the airborne precautions.
And I reminded myself that while vigilance for measles right now is appropriate and necessary, there are still plenty of other causes for fever and rash. Perhaps we should build that into the next EMR pop-up alert?
*Some of the details of this case have been adjusted to protect patient privacy.