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Presentation: In July Annie attended summer camp Exanthebago for the first time. Annie is a 9-year old girl in excellent health and has previously received all of the childhood immunizations required for entrance to the New York City public school system. Camp Exanthebago is in the Berkshire Mountains of Massachusetts only 5 miles from the New York State border. The summer camp houses the children in groups of 15 in ventilated one story dormitories and each child is assigned to a bunk style bed. Annie received the lower level bunk-bed. Two weeks after her entrance at the camp Annie complained to the bunk counselor of a severe headache and was sent to the camp infirmary. The nurse on attendance took her oral temperature and noted that it was 39.4 deg C. The physician’s assistant (PA) that the camp had under contract was immediately called and asked to examine Annie.
Physical examination: The PA noted that Annie was feverish and the headache continued. Her appetite was not good and she was slightly dehydrated. Annie was communicative but tired, was content to remain in the infirmary bunk-bed to read books and watch videos. The PA recommended that the fever should be monitored frequently and that one day after the headache subsided and the temperature returned to normal Annie may return to her camp dormitory.
The camp nurse called Annie’s parents and told them that their daughter was in the infirmary with a fever and headache but could join camp activities about a day after her symptoms subsided. The PA was scheduled to return to watch Annie’s progress. The following day the PA noted that Annie still had a fever and complained of an intermittent headache. Her appetite remained poor. She spoke with her parents by telephone and said that she would like to try to remain at camp and return to all activities when she was feeling better. The camp nurse said that she and the PA would watch Annie’s symptoms carefully and hopefully she would be feeling better in a day or so.
On the third day Annie still had a headache, a poor appetite, was listless, and the fever remained at about 40 deg C. The camp nurse again called Annie’s parents stating, on the advice of the PA that Annie might be taken to a local hospital for a detailed examination, if they gave permission. Alternatively Annie could be retrieved from camp and brought home to be examined by her own pediatrician. Annie also spoke with her parents and said that she now wanted to return home “until she felt better”.
Annie was brought home from camp and immediately taken to the local pediatrician. The results of the physical examination showed that the same symptoms that the PA described. Specimens were taken and sent to Quest Diagnostics for analysis and the laboratory analysis was completed the next day (Tables 1 and 2).
Table 1. Differential diagnosis
|
Test |
Result |
| Borrelia burgdorferi (Lyme disease) | negative |
| Epstein Barr VCA IgM | negative |
| Epstein Barr VCA IgG | pending |
| Epstein Barr nuclear antigen-1 | pending |
|
Conclusion |
Lyme disease (neg) EBV (neg) |
Table 2. List of results out of normal range
|
Laboratory findings |
Normal range |
| Carbon dioxide 20 | 21-33 mmol/L |
| Total cholesterol 121 | 125-170 mg/dl |
| HDL cholesterol 31 | 37-75 mg/dL |
| Total bilirubin 1.0 | 0.2-0.8 mg/dL |
|
Alkaline phosphatase 172 |
184-415 U/L |
| AST 36 | 12-32 U/L |
| Total iron 24 | 27-164 mcg/dL |
| WBC 2.6 | 4.5-13.5 Thous/mcL |
| Platelet count 124 | 140-400 thous/mcL |
| Absolute neutrophils 1279 | 1500-8000 cells/mcl |
| Absolute lymphocytes 8790 | 1500-6500 Cells/mcl |
| Absolute eosiophil 5 | 15-500 cells/mcl |
Annie remained in bed for 3 more days. After her 3rd day at home she developed a sudden rash that began on the body and spread to the arms and legs. The rash consisted of pale, reddish spots (figures 1 and 2).
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Resolution: Annie’s parents called her pediatrician again and reported this new clinical development. The pediatrician was not concerned and said that it was the final stage of the illness and that the fever should have already broken. Indeed her oral temperature now read 37 deg C and Annie reported that the headache was gone. The pediatrician said that the illness was “Roseola-like”, a common summer illness in children. He claimed the rash represented “the release of millions of viral particles”.
Twelve hours later the rash rapidly faded and by twenty four hours was entirely gone. One day after the rash’s disappearance Annie returned to Camp Exanthebago.
Links
and Recommended web sites:
New England Journal of Medicine
New England Journal of Medicine
QUESTIONS and ANSWERS:
1. What is the differential diagnosis for childhood exanthems?
ANSWER:
2. Describe the clinical features of this illness.
ANSWER:
3.
Explain the epidemiology (including mode of transmission) of this disease .
ANSWER:
4. What are the properties of HHV-6?
ANSWER:
5. What is the pathogenisis of HHV-6?
ANSWER:
6. What are the laboratory diagnostic methods used to identify HHV-6?
ANSWER:
7. What (if any) treatment exists for this virus infection?
ANSWER:
