MEASLES IN CHILDREN

A CASE REPORT

dr. Dinda Yuliasari

Wates Husada Hospital, Gresik

ABSTRACT

Background : Measles refers to one of the infectious diseases which is caused by measles virus and
paramyxovirus groups entering to human mucosal from nasopharyngeal secretions. In 2014, the case
of Measles was having an increase in Indonesia. Because of it, a clinical symptom happen to form in
three stages, namely prodromal, exanthema, and convalesence. Diagnosis is then conducted by having
history taking, examination on physical trait, and laboratory-based test. Purpose : This research aims
to unveil the clinical sign and the treatment of measles. Case : An-6 years old-girl who was presented
with rash in her body came to outpatients general clinic in Wates Husada Hospital. The rash
happened to appear two days ago. She also suffered high fever, sore throat and coryza. Based on
physical examination, the consciousness was known to be compos mentis with body temperature on
39,80C. It was apso found a conjungtival injection and lacrimation in both of her eyes. Based on
dermatology examination, disseminated erythematous macules and papules in her neck, trunk, arms,
and legs were found. The laboratory test was shown that her condition was on normal limit. The
diagnosa was established due to the measles by anamnesa and clinical findings. Case Management :
The patient was decided to be hospitalized and to be treated with symptomatic therapy and Vitamin A
1x 200.000 IU.

Keywords : measles, erythematous macules, vitamin A

ABSTRAK

Latar Belakang : Campak adalah penyakit infeksi menular yang disebabkan oleh virus campak , grup
Paramyxovirus yang dapat masuk ke dalam mukosa tubuh manusia melalui sekresi dari nasofaring.
Pada tahun 2014, kasus penyakit campak meningkat di Indonesia. Gejala klinis penyakit campak
terjadi pada tiga stadium : gejala prodromal, stadium eksantem dan stadium konvalesen. Diagnosis
dapat ditegakkan melalui anamnesa, pemeriksaan fisik dan pemeriksaan laboratorium. Tujuan :
untuk mengetahui gejala klinis dan terapi Kasus : Seorang pasien anak perempuan berusia 6 tahun,
datang ke poli umum Rumah Sakit Wates Husada dengan keluhan timbul bercak merah di seluruh
tubuh sejak 2 hari yang lalu. Pasien tersebut juga demam, batuk dan pilek. Pada pemeriksaan fisik
didapatkan kesadaran kompos mentis, suhu tubuh 39,80C, mata merah dan berair. Pada pemeriksaan
kulit didapatkan makula erythematous generalisata dan papul pada badan dan ekstrimitas. Pemeriksaan
laboratorium menunjukkan hasil yang normal. Diagnosa ditegakkan sebagai Campak berdasarkan
anamnesa dan pemeriksaan fisik. Manajemen Kasus : Pasien dirawatinapkan dan mendapatkan terapi
simptomatik serta vitamin A 1x200.000 IU.

Kata kunci : Campak, Makula erythematus, Vitamin A.

Measles in Children Page 1

INTRODUCTION

Measles is one of an infectious exanthema, which is a generalized cutaneous, eruption associated

with a primary systemic infection.1 It is one of the highest cause of the death in children, highly
infectious, can be transmitted from the outset prodromal period (4 days before rash appears) until
approximately 4 days after appearance of the rash. 2,3 Measles arise from exposing droplet containing
measles virus. Since measles immunization program had launched, the number of cases decreased, but
recently it is increasing. 4,5
In United States of America, measles was reported as an ‘outbreak’ from January 2015 to February
2015 with 147 cases.6 While in Indonesia, measles still occur and there were reported that the case was
increasing in 2014.4
CASE REPORT

An-6 year old-girl came to Outpatient General Clinic in Wates Husada Hospital in December, 8
2014 with rash over her body. The rash had appeared 2 days ago, from the neck and spreaded to her
trunk, arms and legs. She sometimes felt itchy. She also got high fever, malaise, sore throat and coryza
with serous secret since 5 days before the rash appeared. She did not feel short of breathing. Her
parents said that some of their daughter’s friends in school had suffered from this disease. Parents
forgot whether her daughter had got measles immunization or not when she was baby. Her parents
also said that her daughter did not take any medication before, and she did not have allergic history.
Her appetite was normal.
From the physical examination, can be concluded that her consiousness was compos mentis. The
body temperature was 39,80 C. Respiration rate was 24 x / minutes, and pulse rate was 98 x / minutes.
There were hyperemia in conjungtiva on both eyes. There was no faryngitis and there was no lymph
enlargment on her neck.
From the dermatology examination, there were disseminated maculopapular rash, confluen, and
papules in face, neck, trunk and extremities.
Laboratory examination showed with normal limit of Complete Blood Count.

Picture 1
Maculopapular rash in trunk and extremities

Measles should be distinguished from another infectious exanthems which has form of
maculopapular rash. Classical clinical symptoms of measles is the prodromal stage of fever that is
accompanied by coryza, cough, conjunctivitis, and maculopapular rash spreading. 1,8,10
Another infectious exanthems are :
1. Rubella (German Measles)
The symptoms are milder than measles and there is not coughing.
2. Roseola Infantum
The symptoms are milder and fever subsides when rash appear.
3. Scarlet Fever
Fever accompanied with faryngitis,but there is no coryza and conjunctivitis .
Based on history taking, physical and dermatology examination, the working diagnose of this
patient is measles. Patient was hospitalized for 5 days, and the therapy were IVFD D5 ½ NS 1000cc in

Measles in Children Page 2

24 hours. Symptomatic therapy such as Paracetamol 3 x 250mg and vitamin A 1 x 200.000 IU single
dose.

Picture 2
Covalesence macule when the patient was discharged

DISCUSSION

A. Epidemiology

Measles is endemic throughout the world, in 2013 occurred 145 700 deaths caused by measles
all over the world (around 400 deaths every day or 16 deaths every hour) on the majority of
children less than 5 years.3
Based on the report of Director of Health PP & PL RI 2014, there are still many cases of
measles in Indonesia with the number of cases reportedly reached 12 222 cases. Outbreak
frequency are 173 events with 2,104 cases. Most cases of measles occured in children ages pre-
school and primary school age. During the 4-year period, more measles cases were more common
in the age group 5-9 year (3591 cases) and age groups 1- 4years (3383 cases). 5

PICTURE 3
Insidence rate of measles
Based on age-groups in indonesia in 2014
Refference : Ditjen PP&PL, Kemenkes RI, 2015

B. Etiology

Measles is an acute viral disease caused by RNA viruse of the genus morbillivirus, family
Paramyxoviridae.2,6,7 This virus has the same family with the mumps virus (mumps),
Parainfluenza Virus, Human Metapneumovirus, and RSV (Respiratory Syncytial Virus). 6
Measles virus is measuring 100-250 nm and has a core containing a single RNA strand
covered with a protective layer of lipids. Measles virus has 6 main protein structure . 7
C. Pathophysiology

The infection dissemination occurs by inhalating droplet in the air from the infected human.
Measles virus is entering through the respiratory tract and penetrated into the epithelial cells of
the respiratory tract. Once attached, the virus replicates and followed by deployment into the
regional lymph nodes. After this deployment, primary viremia occurs and followed by virus
multiplication in reticuloendothelial system in the spleen, liver, and lymph nodes. Virus
multiplication also occur in the first initial attachment of the virus. On day 5 to 7 of infection,

Measles in Children Page 3

 secondary viremia occurs throughout the body, especially the skin and Respiratory tract system.
On the 11th day to 14th, virus stay in the blood, respiratory tract, and other organs,but 2-3 days
later virus began to reduce in number. During infection, virus replicates in endothelial cells,
epithelial cells, monocytes, and macrophages.
Clinical symptoms occur after a period of incubation, consists of three stages:
a. Prodromal
Lasts about 3 days (range 2-4 days), characterized by fever that can reach 39.5 0C ±
1.1 C. Another symptoms are malaise,coryza (acute inflammation of the membrane
0

mucosa of the nasal cavity), conjunctivitis, and cough. Respiratory tract symptoms
resemble the symptoms of respiratory tract infection which caused by another viruses.
Conjunctivitis can be accompanied by watery eyes and sensitivity to light
(photophobia).
Pathognomonic sign form Buccal mucosa which are called Koplik spot appears on day
2 or day 3 of fever.2,6,8
These patches is small, irregularly shaped and colored bright red stain with grayish
white spot in the middle. Koplik’s Spot appears approximately 12 hours,so it is difficult
to be detected and the examiner sometimes miss it.9
b. Exanthem
Macular rash appears with centrifugal model. It begins from hairlines behind the ears
and then spreading to face, neck, trunk and extremities. This may occur for 6-7 days.
Fever generally culminates (reaches 40 0C) on day 2-3 after the appearance of the
rash.2,6,8 If the fever persists after day 3 or 4th generally it indicates complications.
c. Convalesense
Generally 3-4 days after the rash gradually disappeared in accordance with the
pattern of onset. Skin rash disappeared and turned into brown rash and will disappear in
7-10 days.2,8,11

Diagnose of measles could be established by history taking ( anamnesa ), include fever, cough,
runny nose, red eyes, and a rash that often starts from behind the ear to the whole body. From
physical examination such as high body temperature(> 380C), red eyes, and maculopapular rash.
Laboratory examination shows leucopenia, limfocytopenia, and IgM which can be detected
from the first day rash appearance and stay for 1 month. 5-7
The treatment of uncomplicated measles is supportive, such as bed rest, antipyretics
(paracetamol 10-15 mg / kg / dose can be given to every 4 hours), enough liquid, nutritional
supplements, and vitamins A.2,11,12 Vitamin A can serve as immunomodulator, to increase
response antibodies against the measles virus. Vitamin A can reduce the incidence complications
such as diarrhea and pneumonia. Vitamin A given once per day for 2 days with a dose as follows:
2,6-8,10,11,13

- 200,000 IU for children aged 12 months or more

- 100,000 IU for children aged 6-11 months

- 50,000 IU in children under 6 months

Complications commonly occurs in children with high risk, :

2.10

- A young age, especially under 1 year

- Malnutrition (marasmus or kwashiorkor)

- Densely populated settlements with dirty environment

Measles in Children Page 4

 - Children with immune disorders,for example in HIV-infected children,malnutrition and
malignancy

- Children with vitamin deficiency

Complications can occur in various organs body, among others:

2,6,8,10

- Respiratory tract: bronchopneumonia,laryngotracheobronchitis (Croup)

- Digestive tract: diarrhea that can followed by dehydration

- Ear: otitis media

- CNS : Acute Encephalytis, Subacute Sclerosing Panencephalitis (SSPE)

Measles is self-limited disease but very infectious. Mortality and morbidity increase in
patients with high risk factors that affect the onset of complications. In developing countries, the
death reached 1-3%, and may rise to 5-15% when there is an outbreak of measles. 2
The prevention to measles is by vaccination against measles or MMR vaccination ( Measles,
Mumps, Rubella). According to immunization schedule IDAI recommendation in 2014, measles
vaccine can be given at 9 months of age. Furthermore, the booster vaccine can be given at age 2
year. If the MMR vaccine is given at age 15 months, the children does not need to be vaccinated
against measles at the age of 2 years. Furthermore, MMR booster given at age 5-6 years. 9,14
Measles vaccine dose or MMR vaccine is 0.5 mL subcutaneously. 9
CONCLUSION
Measles is a disease that is very infectious caused by the measles virus which is transmitted
through droplet. Clinical manifestations include fever, cough, runny nose, conjunctivitis, and a
maculopapular rash all over the body. The management is generally supportive accompanied
administration of vitamin A according to patient age. Prevention is by immunization measles
vaccine or MMR vaccine.

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penyakit dan penyehatan lingkungan tahun 2014. Jakarta; 2015. p. 25-7

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