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Measles: Overview

(Aka: Rubeola, Morbilli, 9-Day Measles)


Highly contagious viral infection
Paramyxovirus - spread mainly by secretions from the nose, throat, and mouth during
prodromal or early eruptive stage
Transmission is typically by large respiratory droplets (airborne)
can remain airborne (ie, can be inhaled) for up to 2 h in closed areas (eg, in an office examination room)

Most common among children


Characterized by fever, cough, coryza, conjunctivitis, an enanthem (Koplik spots)
on the oral mucosa, and a maculopapular rash that spreads cephalocaudally
Diagnosis is usually clinical
Treatment is supportive
Vaccination is highly effective
In the US, almost all measles cases are imported by travelers or immigrants, with subsequent
indigenous transmission occurring primarily among unvaccinated people.

Measles: Presentation
Prodromal phase is marked by malaise, fever, anorexia, and the
classic triad of conjunctivitis, cough, and coryza (the 3 Cs)
HIGH FEVER - often >104o F [40o C]; lasting 4-7 days
Other possible associated symptoms include photophobia, periorbital edema,
and myalgias
Koplik spots bluish-gray specks or grains of white sand on a red base
develop on the buccal mucosa opposite the second molars

Rash appears 2-4 days after the onset of the prodrome (1-2 days after
the appearance of Koplik spots) and lasts 3-5 days.
Entire course of uncomplicated measles, from late prodrome to
resolution of fever and rash, is 7-10 days. Cough may be the final
symptom to appear.

Measles: Rash

Blanching, erythematous macules and papules


begin on the face at the hairline, on the sides
of the neck, and behind the ears
Within 48 hours, the lesions coalesce into
patches and plaques that spread
cephalocaudally to the trunk and extremities,
including the palms and soles, while beginning
to regress cephalocaudally, starting from the
head and neck
Lesion density is greatest above the
shoulders, where macular lesions may
coalesce
The eruption may also be petechial or
ecchymotic in nature
Patients appear most ill during the first or
second day of the rash
The exanthem lasts for 5-7 days before fading
into coppery-brown hyperpigmented patches,
which then desquamate
Immunocompromised patients may not
develop a rash

Measles: Complications
Atypical measles syndrome
previously immunized with the original killed-virus measles vaccines (1963-1968)

Pneumonia
occurs in about 5% of patients, even during apparently uncomplicated infection; in infants, it is a common cause of
death

Bacterial superinfection
pneumonia, laryngotracheobronchitis, and otitis media. Measles transiently suppresses delayed hypersensitivity,
which can worsen active TB

Acute thrombocytopenic purpura


may occur after infection resolves and cause a mild, self-limited bleeding tendency

Encephalitis
in 1/1000 to 2000 cases; usually 2 days to 2 wk after onset of the rash, often beginning with recrudescence of high
fever, headache, seizures, and coma

Transient hepatitis
with diarrhea may occur during an acute infect

Subacute sclerosing panencephalitis


a rare, progressive, ultimately fatal, late complication of measles

Measles: Differential Dx
Differential diagnosis includes rubella, scarlet fever, drug rashes, serum sickness, roseola
infantum, infectious mononucleosis, erythema infectiosum, and echovirus and coxsackievirus
infections.
Manifestations can also resemble Kawasaki disease and cause diagnostic confusion in areas
where measles is very rare.
Atypical measles, because of its greater variability, can simulate even more conditions than
typical measles, including Rocky Mountain spotted fever, toxic shock syndromes, and
meningococcemia.
Some of these conditions can be distinguished from typical measles as follows:
Rubella: A recognizable prodrome is absent, fever and other constitutional symptoms are absent
or less severe, postauricular and suboccipital lymph nodes are enlarged (and usually tender), and
duration is short.
Drug rashes: A drug rash often resembles the measles rash, but a prodrome is absent, there is
no cephalocaudal progression or cough, and there is usually a history of recent drug exposure.
Roseola infantum: The rash resembles that of measles, but it seldom occurs in children > 3 yr.
Initial temperature is usually high, Koplik spots and malaise are absent, and defervescence and
rash occur simultaneously.

Measles: Treatment
Supportive care
For children: Vitamin A
Hospitalized patients with measles should be managed with standard contact and airborne
precautions. Single-patient airborne infection isolation rooms and N-95 respirators or similar
personal protective equipment are recommended. Otherwise healthy outpatients with measles
are most contagious for 4 days after the development of the rash and should severely limit
contact with others during their illness.
Vitamin A supplementation has been shown to reduce morbidity and mortality due to measles
in children in the developing world. Because low serum levels of vitamin A are associated with
severe disease due to measles, vitamin A treatment is recommended for all children with
measles. The dose is given orally once/day for 2 days and depends on the childs age:
> 1 yr: 200,000 IU
6 to 11 mo: 100,000 IU
< 6 mo: 50,000 IU

In children with clinical signs of vitamin A deficiency, an additional single, age-specific dose of
vitamin A is repeated 2 to 4 wk later.

Measles: Post-exposure Prophylaxis


Prevention in susceptible contacts is possible by giving the vaccine within 3 days
of exposure
If vaccine should be deferred, immune globulin 0.25 mL/kg IM is given immediately (within
6 days), with vaccination given 5 to 6 mo later if medically appropriate (eg, if the patient is
no longer pregnant)
An exposed immunodeficient patient with a contraindication to vaccination is given
immune globulin 0.5 mL/kg IM
Immune globulin should not be given simultaneously with vaccine

In an institutional outbreak (eg, schools), susceptible contacts who refuse or


cannot receive vaccination and who also do not receive immune globulin should
be excluded from the affected institution until 21 days after onset of rash in the
last case.
Exposed, susceptible healthcare workers should be excluded from duty from 5 days after
their first exposure to 21 days after their last exposure, even if they receive postexposure
prophylaxis.

Measles: Key Points


Incidence of measles is highly variable depending on the vaccination rate in the
population.
Measles is highly transmissible, developing in > 90% of susceptible contacts.
Measles causes about 200,000 deaths annually, primarily in children in the
developing world; pneumonia is a common cause, whereas encephalitis is less
common.
Treatment is mainly supportive, but children should also receive vitamin A
supplementation.
Universal childhood vaccination is imperative unless contraindicated (eg, by
active cancer, use of immunosuppressants, or HIV infection with severe
immunosuppression).
Give postexposure prophylaxis to susceptible contacts within 3 days of
exposure; use vaccine unless contraindicated, in which case give immune
globulin.

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