What are the potential causes and recommended treatments for a college student presenting with a cough, fever, and a rash that started at the hairline and is moving down the body?

Measles Until Proven Otherwise – Immediate Isolation and Public Health Notification Required

This clinical triad of cough, fever, and a rash starting at the hairline and spreading cephalocaudally (downward) in a college student is pathognomonic for measles (rubeola) and requires immediate isolation, public health notification, and supportive care. 1, 2

Immediate Actions Required

• Isolate the patient immediately using airborne precautions (N95 respirator, negative pressure room if available) as measles is one of the most contagious infectious diseases with airborne transmission 1, 2
• Notify public health authorities immediately – measles is a reportable disease and contact tracing must begin urgently given the college setting with high exposure risk 1, 2
• Verify vaccination status – most measles cases in college-aged students occur in unvaccinated or incompletely vaccinated individuals 1, 2

Diagnostic Confirmation

• Obtain measles IgM serology and nasopharyngeal PCR for measles RNA to confirm the diagnosis 1, 2
• Document the classic "3 Cs": cough, coryza (runny nose), and conjunctivitis, which typically precede the rash by 2-4 days 1, 2
• Examine for Koplik spots (small white spots with red halos on the buccal mucosa opposite the molars) – these are pathognomonic for measles and appear 1-2 days before the rash 1, 2

Clinical Course and Management

The characteristic progression is critical for diagnosis:

• Prodrome phase (days 1-4): fever, malaise, cough, coryza, conjunctivitis 1, 2
• Rash phase (days 5-9): maculopapular rash begins at hairline/forehead, spreads downward to face, neck, trunk, and extremities over 3-4 days 1, 2
• Recovery phase (days 10-14): rash fades in same order it appeared, often with desquamation 1, 2

Treatment is entirely supportive – there is no specific antiviral therapy for measles 1, 2:

• Antipyretics (acetaminophen or ibuprofen) for fever control 3
• Adequate hydration and rest 3
• Vitamin A supplementation (200,000 IU for 2 days) reduces morbidity and mortality, particularly in hospitalized patients 1, 2

Critical Differential Diagnoses to Consider

While measles is most likely, other causes of fever with cephalocaudal rash spread include:

• Rubella (German measles): milder illness, less prominent cough, posterior auricular/suboccipital lymphadenopathy 1, 2
• Scarlet fever (Group A Streptococcus): sandpaper-textured rash, strawberry tongue, circumoral pallor 1, 2
• Drug reaction: obtain medication history, but timing and cough make this less likely 1, 2

Complications Requiring Monitoring

Measles can cause severe morbidity and mortality 1, 2:

• Pneumonia (most common cause of measles-related death): monitor for dyspnea, hypoxia, chest pain 1, 2
• Encephalitis (1 in 1,000 cases): monitor for altered mental status, seizures, focal neurologic deficits 1, 2
• Secondary bacterial infections: otitis media, sinusitis, bacterial pneumonia 1, 2

Common Pitfalls to Avoid

• Do not dismiss this as a viral URI with coincidental rash – the specific pattern of hairline-to-downward spread is highly specific for measles 1, 2
• Do not delay isolation while awaiting laboratory confirmation – clinical diagnosis warrants immediate airborne precautions 1, 2
• Do not prescribe antibiotics empirically – measles is viral and antibiotics are only indicated for documented secondary bacterial infections 3
• Do not forget post-exposure prophylaxis for contacts: unvaccinated contacts should receive MMR vaccine within 72 hours or immunoglobulin within 6 days of exposure 1, 2

Contact Investigation in College Setting

Given the college environment, this represents a public health emergency:

• Identify all close contacts in dormitories, classrooms, dining halls within the infectious period (4 days before to 4 days after rash onset) 1, 2
• Verify vaccination status of all contacts – two doses of MMR vaccine provide 97% protection 1, 2
• Implement outbreak control measures as directed by public health authorities, which may include mass vaccination campaigns 1, 2