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  • A 3-year-old girl is brought to the pediatrician’s office for a rash that began on the face and spread to the rest of her body. The rash is sometimes itchy. The girl also has a low-grade fever. She had just moved from South America to the US and had not received her childhood vaccinations. On physical exam, she has postauricular lymphadenopathy, a pink non-confluent maculopapular rash, and petechiae on her soft palate.
  • Classification
    • rubella virus
      • an enveloped, single-stranded, positive-sense RNA virus
      • icosahedral capsid
      • a togavirus
      • causes rubella (German 3-day measles)
      • transmission via respiratory secretions
  • Epidemiology
    • incidence
      • decreased in the US due to vaccination
      • endemic in other parts of the world
    • demographics
      • any age can be affected
    • risk factors
      • lack of vaccination
      • travel to or from endemic areas
  • Pathogenesis
    • the virus replicates in the upper respiratory tract and lymph nodes
    • it then disseminates throughout the body
    • can spread through the placenta to cause vertical transmission
      • may result in miscarriage or congenital rubella syndrome
  • Associated conditions
    • congenital rubella syndrome 
      • blueberry muffin appearance
        • dermal extramedullary hematopoiesis
      • cataracts
      • deafness
      • congenital heart disease (pulmonary artery stenosis or patent ductus arteriosus)
  • Prevention
    • measles, mumps, and rubella (MMR) vaccine
      • given over 2 doses
  • Prognosis
    • infection may be asymptomatic but still contagious
  • Symptoms 
    • low-grade fever
    • polyarthritis and polyarthralgia
      • more common in adult females
      • fingers, wrists, and knees are most commonly involved
  • Physical exam
    • lymphadenopathy before the rash
      • postauricular lymphadenopathy is classic
      • may also have posterior cervical and suboccipital lymphadenopathy
    • fine, pink, non-confluent maculopapular rash
      • starts on face and spreads to trunk and extremities
      • may be itchy
      • desquamates
      • rash resolves in 3 days
    • petechial rash on soft palate (Forschheimer spots)
    • orchitis
  • Labs
    • detection of rubella-specific immunoglobulin M or G
    • detection of virus on reverse transcriptase-polymerase chain reaction
  • Making the diagnosis
    • based on clinical presentation and confirmed with laboratory studies
  • Parvovirus B19 infection
    • distinguishing factors
      • slapped cheek rash
      • maculopapular rash on trunk and limbs that does not spread from head/neck downward
  • Measles
    • distinguishing factors
      • confluent maculopapular rash
      • coryza and Koplik spots
  • Management approach
    • mainstay of treatment is supportive care and prevention with vaccines
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • anti-pyretics
        • analgesics
        • hydration
  • Vertical transmission to fetus
    • congenital rubella syndrome
  • Thrombocytopenic purpura
  • Guillain-Barré syndrome

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Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

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(M1.MC.15.75) A 2-week-old boy is brought to a pediatrician's office for evaluation. The boy was born at 32 weeks. The boy's mother immigrated to the United States from Eastern Europe several years ago. His mother is concerned that he does not appear to awaken to the sound of loud noises. She also notes that his eyes appear "cloudy" (Figure A). He has two older siblings, neither of whom is affected by similar problems. On physical exam, you hear a continuous murmur with machine-like consistency over the precordium. Which of the following is the most likely explanation for this child's problems? Review Topic | Tested Concept

QID: 106711

Toxoplasma gondii



















L 2 D

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(M1.MC.13.11) A 35-year-old woman from San Francisco has been refusing to vaccinate her children due to the claims that vaccinations may cause autism in children. Her 10-year-old male child began developing a low-grade fever with a rash that started on his face; as the rash began to spread to his limbs, it slowly disappeared from his face. When the child was taken to a clinic, the physician noticed swollen lymph nodes behind the ears of the child. Which of the following are characteristics of the virus causing these symptoms? Review Topic | Tested Concept

QID: 101470

Enveloped, DS linear DNA




Nonenveloped, SS linear DNA




Enveloped, SS + nonsegmented RNA




Enveloped, SS - nonsegmented RNA




Nonenveloped, DS segmented RNA



L 2 E

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