Intended for healthcare professionals

Endgames Case Report

Rash in a 15 month old girl

BMJ 2012; 345 doi: (Published 23 October 2012) Cite this as: BMJ 2012;345:e6973
  1. Susannah M C George, specialty registrar in dermatology1,
  2. Milly Sen, paediatric specialist registrar2,
  3. David Elliman, consultant in community child health3
  1. 1Brighton and Sussex University Hospitals NHS Trust, Brighton General Hospital, Brighton BN2 3EW, UK
  2. 2University College London Hospitals NHS Foundation Trust, University College Hospital, London, UK
  3. 3Whittington Health, London
  1. Correspondence to: S George susannah{at}

A 15 month old white girl became unwell on the day after she received her MMR (measles, mumps, and rubella) and pneumococcal vaccinations. These had initially been booked when she was 13 months old but were postponed twice owing to minor illnesses.

On the day after her vaccinations she developed conjunctivitis, a cough, and fever, with gradual worsening of her symptoms over the next few days. Four days after the onset of symptoms, she refused food and had an episode of vomiting. The next day, small erythematous macules appeared behind her ears. Tiny white papules were present on the buccal mucosa. The eruption became papular and spread to her face, trunk, and limbs. The rash gradually became more confluent and maculopapular.

She was previously healthy but had contracted several minor infectious illnesses since starting nursery six months earlier. She had no known contact with anyone with a rash illness and no history of foreign travel. She lived with both parents and had no siblings.


  • 1 What is the most likely cause of the rash?

  • 2 How can this condition be prevented?

  • 3 How would you confirm the diagnosis?

  • 4 What are the complications of this condition?


What is the most likely cause of the rash?

Short answer

Wild-type measles.

Long answer

The differential diagnosis includes infections with parvovirus B19, group A or C streptococcus, rubella, enterovirus, adenovirus, and human herpes virus 6 (roseola infantum) or a vaccination reaction.1 2 However the initial symptoms of malaise, fever, anorexia, cough, conjunctivitis, and coryza are typical of the prodromal phase of measles. The rash showed the characteristic morphology, distribution, and progression (fig 1) of a measles rash.

Fig 1 Top: Initial signs of measles rash in postauricular area; bottom: typical maculopapular eruption

The small white spots on the buccal mucosa were Koplik spots, which are reported to be pathognomonic for measles.3 Koplik spots—irregular …

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