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Infectious Diseases and Immunology

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A 13-year-old boy is seen in the emergency department (ED) with a 3-day history of fever, muscular pain (especially in the neck), headache, and malaise. He reports that drinking sour liquids causes much pain in the affected area. He denies sick exposures, travel, or intake of medications. His past medical history is positive for occasional upper respiratory infections, but no serious illnesses. He has had one sexual encounter and reports condom use; he denies smoking, alcohol, and other drugs. On physical examination the temperature is 38.5°C (101.1°F), heart rate is 88 beats per minute, respiratory rate is 14 breaths per minute, and blood pressure is 100/69 mm Hg. He is awake, alert, and in no distress. Head is without trauma. Neck is supple with the area on the right side from the back of the mandible toward the mastoid space being full and tender. The earlobe on that side is protuberant. The mucous membranes are pink, moist, and without lesions. Extraocular eye movement and fundoscopic examinations are normal. The chest is clear. Heart has a normal S1 and S2 without murmur. The abdomen is soft and nontender. No hepatosplenomegaly or adenopathy is noted. GU examination is Tanner 3 with tender testicles but no mass. Neurologic examination is nonfocal. Which of the following vaccines would have prevented this condition?

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a. Measles-mumps-rubella (MMR)

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b. Varicella

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c. Human papilloma virus (HPV)

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d. Conjugated meningococcal

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e. Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed

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The answer is a. (Hay et al, pp 1265-1266. Kliegman et al, pp 1078-1081. McMillan et al, pp 1279-1281. Rudolph et al, pp 1174-1175.) The child in the question has classic findings of mumps. In addition to the findings described, mumps typically causes swelling of the opposite side a day or so after symptoms appear on the first side. Other findings include redness and swelling at the opening of Stensen's duct, edema and swelling in the pharynx, and displacement of the uvula on the affected side. A rash would not be expected. It is important to note that while mumps has largely been eliminated with vaccination, other organisms still may cause parotitis. Measles presents in a child with a several days' history of malaise, fever, cough, coryza, and conjunctivitis followed by the typical, widespread, erythematous, maculopapular rash. Koplik spots, white pinpoint lesions on a bright red buccal mucosa often in the area opposite his lower molars, appear transiently and are pathognomonic. Symptoms of rubella, usually a mild disease, include a diffuse maculopapular rash that lasts for 3 days, marked enlargement of the posterior cervical and occipital lymph nodes, low-grade fever, mild sore throat, and, occasionally, conjunctivitis, arthralgia, or arthritis. Signs and ...

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