Measles (Rubeola)

Definition
A highly contagious, acute, exanthematous respiratory disease with a pathognomonic enanthem: Kopliks spots, an eruption on the buccal mucous membranes

Kopliks spots, which manifest as white or bluish lesions with an erythematous halo on the buccal mucosa

Etiologic agent
Measles virus is the only member of the genus Morbillivirus that infects humans. Measles virions are pleomorphic spherical structures having a diameter of 100 to 250 nm and consisting of six proteins. The inner capsid is composed of a coiled helix of RNA and three proteins, and the outer envelope consists of a matrix protein bearing two types of short surface glycoprotein projections or peplomers.

Epidemiology
According to the WHO, measles is a leading cause of vaccine-preventable childhood mortality. Measles has a worldwide distribution; humans are the only natural hosts. During the prevaccination era in the United States, measles epidemics occurred every 2 to 5 years in the winter and spring. The foremost reason for the resurgence of measles was failure to immunize infants and young children, especially in inner-city areas.

Transmission
Measles virus is transmitted by respiratory secretions, predominantly through exposure to aerosols but also through direct contact with larger droplets. Patients are contagious from 1 or 2 days before the onset of symptoms until 4 days after the appearance of the rash. Infectivity peaks during the prodromal phase. The mean intervals from infection to onset of symptoms and to appearance of rash are 10 and 14 days, respectively.

Risk Factors
Incomplete immunization: Missed a dose of the MMR vaccine Pregnancy Crowded living conditions Day care Weak immune system: AIDS Cancer Organ transplant Chemotherapy

Pathogenesis
Measles virus invades the respiratory epithelium and spreads via the bloodstream to the reticuloendothelial system

from which it infects all types of white blood cells

establishing infection of the skin, respiratory tract, and other organs

Infection of the entire respiratory tract accounts for the characteristic cough and coryza of measles and for the less frequent manifestations of croup, bronchiolitis, and pneumonia.

 Patients who are deficient in cellular immunity are at high risk for severe measles. Immune reactions to the virus in the endothelial cells of dermal capillaries play a substantial role in the development of Kopliks spots (the pathognomonicenanthem) as well as in that of rash Pathologic changes in measles encephalitis include focal hemorrhage, congestion, and perivascular demyelination.

Generalized damage to the respiratory tract

resultant loss of cilia

predisposes to secondary bacterial infections such as pneumonia and otitis media.

Clinical manifestation
respiratory prodrome of malaise, cough, coryza, conjunctivitis with lacrimation, nasal discharge, and increasing fever . Kopliks spots erythematous, nonpruritic, maculopapular rash of measles

Day 2-4

Day 4-10

rash begins to fade Brownish discoloration of the skin and desquamation Fever usually resolves after the onset of rash Lymphadenopathy, diarrhea, vomiting, and splenomegaly

The entire illness usually lasts about 10 days Day 10

In measles, discrete erythematous lesions become confluent as the rash spreads downward.

Complication
The complications of measles can conveniently be divided into three groups, according to the site involved: 1. the respiratory tract, 2. the central nervous system (CNS) 3. the gastrointestinal tract.

 Gastrointestinal complications of measles include gastroenteritis, hepatitis, appendicitis, ileocolitis, and mesenteric adenitis. Other, rare complications include myocarditis, glomerulonephritis, and postinfectious thrombocytopenic purpura. Measles can exacerbate preexisting tuberculosis, presumably through depression of cellular immunity induced by the virus.

Laboratory findings
Lymphopenia and neutropenia are common in measles and may be due to invasion of leukocytes by the virus, with subsequent cell death. Leukocytosis may herald a bacterial superinfection. Patients with measles encephalitis usually have an elevated protein concentration in CSF as well as lymphocytosis.

Diagnosis
A specific diagnosis of measles can be made quickly by immunofluorescent staining of a smear of respiratory secretions for measles antigen Measles virus can be isolated from respiratory secretions or urine and rapidly identified in tissue culture with fluorescein-labeled monoclonal antibodies. Enzyme Immunoassay (EIA) can be used to measure specific IgM and thus to diagnose measles on the basis of an acute-phase serum sample alone. Specific IgM antibodies are detectable within 1 to 2 days after the appearance of rash, and the IgG titer rises significantly after 10 days.

Prevention
The development of live attenuated measles vaccine since 1963, induces seroconversion in about 95% of recipients and probably confers lifelong protection. For the past three decades, measles vaccine has been available as the combination vaccine measles-mumps-rubella (MMR); MMR vaccine should be administered to children between the ages of 12 and 15 months. A second dose of MMR vaccine is recommended for school-age children at 4 to 12 years of age. Approximately 10% of healthy vaccinees develop a fever, with temperatures up to 39.4C (103F), 5 to 7 days after vaccination Measles vaccine is contraindicated for persons with impaired cellmediated immunity, for pregnant women, and for persons with a history of anaphylaxis due to egg protein or neomycin.

Therapy
Therapy for measles is largely supportive and symptom based. Patients with otitis media and pneumonia should be given standard antibiotics. Patients with encephalitis need supportive care, including observation for increased intracranial pressure. Vitamin A treatment is recommended for young children hospitalized for measles and for pediatric measles patients with immunodeficiency, etc. A dose of 50,000 IU infants 1 to 6 months old; Single dose A dose of 100,000 IU infants 7 to 12 months old for 2 days A dose of 200,000 IU children 1 year old. Transient vomiting and headache may be associated with the administration of vitamin A.