BUENAVENTURA, FAUSTA B.

BSM 3A-OLD
MID 105
PROF. NIDA RAMOS

Measles is a highly contagious viral infection that is most common among children. It is
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.
Pathophysiology
Measles is caused by a paramyxovirus and is a human disease with no known animal reservoir or
asymptomatic carrier state. It is extremely communicable; the secondary attack rate is > 90%
among susceptible people who are exposed.

Measles is spread mainly by secretions from the nose, throat, and mouth during the prodromal or
early eruptive stage. Communicability begins several days before and continues until several
days after the rash appears. Measles is not communicable once the rash begins to desquamate.

Transmission is typically by large respiratory droplets that are discharged by cough and briefly
remain airborne for a short distance. Transmission may also occur by small aerosolized
droplets that can remain airborne (and thus can be inhaled) for up to 2 hours in closed areas
(eg, in an office examination room). Transmission by fomites seems less likely than airborne
transmission because the measles virus is thought to survive only for a short time on dry
surfaces.

An infant whose mother has immunity to measles (eg, because of previous illness or
vaccination) receives antibodies transplacentally; these antibodies are protective for most of
the first 6 to 12 months of life. Lifelong immunity is conferred by infection. In the US, almost
all measles cases are imported by travelers or immigrants, with subsequent indigenous
transmission occurring primarily among unvaccinated people.

Symptoms and Signs

After a 7- to 14-day incubation period, measles begins with a prodrome of fever, coryza,
hacking cough, and tarsal conjunctivitis. Pathognomonic Koplik spots appear during the
prodrome, before the onset of rash, usually on the oral mucosa opposite the 1st and 2nd upper
molars. The spots resemble grains of white sand surrounded by red areolae. They may be
extensive, producing diffuse mottled erythema of the oral mucosa. Sore throat develops.
The rash appears 3 to 5 days after symptom onset, usually 1 to 2 days after Koplik spots
appear. It begins on the face in front of and below the ears and on the side of the neck as
irregular macules, soon mixed with papules. Within 24 to 48 hours, lesions spread to the trunk
and extremities (including the palms and soles) as they begin to fade on the face. Petechiae or
ecchymoses may occur with severe rashes.

Measles (Macular Rash)

During peak disease severity, a patient’s temperature may exceed 40° C, with periorbital
edema, conjunctivitis, photophobia, a hacking cough, extensive rash, prostration, and mild
itching. Constitutional symptoms and signs parallel the severity of the eruption and the
epidemic. In 3 to 5 days, the fever falls, the patient feels more comfortable, and the rash fades
rapidly, leaving a coppery brown discoloration followed by desquamation.
Immunocompromised patients may not have a rash and can develop severe, progressive giant
cell pneumonia.

Complications
Complications of measles include
  Pneumonia
 Bacterial superinfection
 Acute thrombocytopenic purpura
 Encephalitis
 Transient hepatitis
 Subacute sclerosing panencephalitis

Pneumonia due to measles virus infection of the lungs occurs in about 5% of patients, even
during apparently uncomplicated infection; in infants, it is a common cause of death.

Diagnosis

 Clinical evaluation
 Serologic testing
 Viral detection via culture or reverse transcription–polymerase chain reaction
(RT-PCR)

Typical measles may be suspected in an exposed patient who has coryza, conjunctivitis,
photophobia, and cough but is usually suspected only after the rash appears. Diagnosis is
usually clinical, by identifying Koplik spots or the rash in an appropriate clinical context. A
complete blood count is unnecessary but, if obtained, may show leukopenia with a relative
lymphocytosis.

Laboratory confirmation is necessary for public health and outbreak control purposes. It is
most easily done by demonstration of the presence of measles IgM antibody in an acute serum
specimen or by viral culture or RT-PCR of throat swabs, blood, nasopharyngeal swabs, or
urine samples. A rise in IgG antibody levels between acute and convalescent sera is highly
accurate, but obtaining this information delays diagnosis. All cases of suspected measles
should be reported to the local health department even before laboratory confirmation.

Treatment

 Supportive care
 For children, vitamin A

Treatment of measles is supportive, including for encephalitis.

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 a day for 2 days and depends on the child’s age:

 > 1 year: 200,000 international units (IU)

 6 to 11 months: 100,000 IU

 < 6 months: 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 weeks later.

Prevention

A live-attenuated virus vaccine containing measles, mumps, and rubella is routinely given to
children in most developed countries (also see Table: Recommended Immunization Schedule
for Ages 0–6 Years and see Table: Recommended Immunization Schedule for Ages 7–18
Years). Two doses are recommended:

 The first dose is recommended at age 12 to 15 months but can be given as young
as age 6months during a measles outbreak or before international travel.
 The second is given at age 4 to 6 years.

Infants immunized at < 1 year of age still require 2 further doses given after the first birthday.
Vaccine provides long-lasting immunity and has decreased measles incidence in the US by
99%. The vaccine causes mild or inapparent, noncommunicable infection. Fever > 38° C
occurs 5 to 12 days after inoculation in 5 to 15% of vaccinees and can be followed by a rash.
Central nervous system reactions are exceedingly rare; the measles vaccine does not cause
autism.