Measles (Rubeola, First Disease)
Measles (Rubeola, First Disease): Excerpt from The 5-Minute Pediatric Consult
Jeffrey S. Gerber, MD, PhD
Measles - BASICS
Measles - description
- An exanthematous disease that has a relatively predictable course, making diagnosis clinically possible.
- Misdiagnosis is the biggest problem with measles infection. Because it is rare and may occur in outbreaks, initially cases are often misdiagnosed as Kawasaki disease or Stevens-Johnson syndrome.
- Patients are contagious from 1–2 days before onset of symptoms until 5 days after the appearance of the rash. The incubation period is generally 8–12 days from exposure to onset of symptoms and ~14 days until the appearance of rash.
- Types of measles include the following:
- Typical measles
- Modified measles: Occurs naturally in infants younger than 9 months old because of the presence of transplacental antibody or administration of immunoglobulin to an exposed susceptible child.
- The illness is similar to typical measles but is generally mild.
- The patient may be afebrile and the rash may last 1–2 days.
- Atypical measles: Occurs because of a hypersensitivity reaction to measles infection in those who received killed virus vaccine between 1963 and 1967 and are subsequently exposed to wild-type virus.
Measles - general prevention
- Vaccine recommendations:
- Routine vaccination against measles, mumps, rubella (MMR) for children begins at 12–15 months of age, with a second MMR vaccination at entrance to elementary school (age 4–6 years).
- With the recent resurgence of measles, aggressive employee immunization programs should be pursued for all health care workers.
- Health care workers born in 1957 or after who have no documentation of vaccination or other evidence of measles immunity should be vaccinated at the time of employment and revaccinated no sooner than 1 month later.
- Infection control measures:
- Any inpatient suspected of having measles should be in a negative-pressure respiratory isolation room.
- All health care workers involved with the patient must wear masks, gloves, and gowns.
- Isolation is required until 5 days after the 1st appearance of the rash, except for immunocompromised patients, who require isolation for the course of the illness.
- All suspected cases of measles should be reported immediately to the local health department.
Measles - epidemiology
- Measles is a highly contagious disease in nonimmune persons.
- Hospital or clinic waiting rooms (especially pediatric emergency department waiting rooms) have been identified as a major risk, accounting for up to 45% of the known exposures.
- With adequate immunization (2 doses 99% effective), measles could be eliminated as a disease. It is no longer endemic in the US, and goals have been set for worldwide elimination.
Measles - incidence
- Before the 1963 licensure of vaccine, approximately 500,000 cases of measles (330 cases per 100,000) population were reported annually.
- By 1983, there were only 0.7 cases per 100,000 population.
- Delays in immunization facilitated large outbreaks in the US from 1989–1991, peaking in 1990 when 27,672 cases were reported, 89 of which were fatal.
- From 1997–2001 only 540 cases of measles were reported to the Centers for Disease Control (CDC), 67% of which were associated with international importation.
Measles - pathophysiology
Transmission of measles is thought to occur mainly by microaerosolized droplets of respiratory secretions.
Measles - etiology
- Measles is a paramyxovirus, genus Morbillivirus.
- 1st isolated in 1954 in human and monkey kidney tissue cultures
Measles - DIAGNOSIS
Measles - signs & symptoms
- The disease involves fever, cough, conjunctivitis, or coryza with an erythematous rash, which has a characteristic progression.
- The rash appears on the face (often the nape of the neck, initially) and abdomen 14 days after exposure. The rash is erythematous and maculopapular and spreads from the head to the feet often becoming confluent at the more proximal sites.
- Pharyngitis, cervical lymphadenopathy, and splenomegaly may accompany the rash.
- Atypical measles:
- This group of young adults (2nd and 3rd decades of life) may become quite ill, with sudden onset of fever from 103–105°F associated with headache. The rash, unlike typical measles, appears 1st on the distal extremities and progresses in a cephalad direction.
- Virtually all patients with atypical measles have respiratory distress with clinical and radiographic signs of pneumonia, often with pleural effusions.
- Diagnosis depends on recognition and on acute and convalescent measles antibody titers.
Measles - history
- Case definition from the CDC includes:
- Generalized rash lasting 3 days or longer
- A temperature of 38.3°C (101°F) or higher and cough, coryza, or conjunctivitis
- The mean incubation period is 10 days (range: 8–21 days).
- The prodrome of measles lasts 2–4 days and begins with symptoms of upper respiratory infection and fever up to 104°F. General malaise, conjunctivitis with photophobia, and cough increasing in severity over this period
- During the prodrome, Koplik spots (white spots on the buccal mucosa) appear on most people.
- The rash appears on the face (often the nape of the neck, initially) and abdomen 14 days after exposure. The rash is erythematous and maculopapular and spreads from the head to the feet.
- After 3–4 days, the rash begins to clear, leaving a brownish discoloration and fine scaling.
- Fever usually resolves by the 4th day of rash.
Measles - tests
- The course of typical measles follows a predictable pattern; therefore, laboratory studies to confirm infection are rarely indicated.
- At the beginning of a suspected case, confirmation of the index cases is important.
Measles - lab
- Nasopharynx culture:
- Virus may be cultured from the nasopharynx if inoculated into tissue culture within 24 hours of the onset of rash.
- Measles-specific IgM titer
- Sensitivity may be diminished if assay performed <72 hours from onset of rash; repeat if negative. IgM detectable for at least 1 month from onset of rash.
- A comparison of IgG titers obtained during the acute and convalescent stages can be done. Blood samples must be taken at least 7–10 days apart.
- Monoclonal antibody immunofluorescence
- Rapid detection of measles virus from nasal secretions is also possible.
- Measles infected with epithelial cells will demonstrate fluorescence. However, after the 3rd day of rash, detection of virus by the method becomes increasingly difficult.
Measles - differencial diagnosis
With a careful history and physical examination, it is usually possible to rule in measles and rule out other possibilities. Differential diagnosis includes the following:
- Steven-Johnson syndrome
- Kawasaki disease
- Viral exanthem
- Meningococcemia
- Rocky Mountain spotted fever (RMSF)
- Toxic shock syndrome
Measles - TREATMENT
Measles - general measures
- No specific therapy for this infection other than supportive care.
- Ribavirin active in vitro, but not approved by US FDA for treatment of measles.
- Antipyretics, oral fluids, and room humidification to help reduce cough are usually all that is needed.
- In April 1993, the American Academy of Pediatrics issued a policy statement concerning vitamin A treatment of measles.
- The use of vitamin A should be considered for children ages 6 months to 2 years of age who are hospitalized with measles or its complications; and
- Children older than 6 months of age who have an immunodeficiency, ophthalmologic evidence of vitamin A deficiency, impaired intestinal absorption, or moderate to severe malnutrition, or who are recent immigrants from areas of high mortality from measles.
- Children ages 6 months to 1 year should receive 100,000 IU of water-miscible vitamin A.
- The recommended dosage for children over 1 year of age is a single dose of 200,000 IU of water-miscible vitamin A on admission, with a 2nd dose the following day.
- The higher dose may be associated with vomiting and headache for a few hours.
- For children with ophthalmologic evidence of vitamin A deficiency, a 3rd dose at 4 weeks is indicated.
- Vitamin A is available in 50,000-IU/mL solution and may be given orally.
Measles - FOLLOW UP
In uncomplicated measles infection the patient begins feeling better with a fading of rash on the 3rd and 4th day.
Measles - prognosis
- Mortality in the modern outbreak of 1989–1990 occurred in 3 of every 1,000 cases in the United States.
- Case fatality rates are increased in immunocompromised children.
Measles - complications
- Complication rates in 1989–1990 outbreaks that occurred throughout the country were 23% and included diarrhea (9%), otitis media (7%), pneumonia (6%), and encephalitis (0.1%).
- Encephalitis, which can lead to permanent neurologic sequelae, occurs in 1 of every 1,000 cases reported in the US.
- In 1990, ~18–20% of patients required hospitalization, many for either dehydration or pneumonia.
- In patients with poor nutrition, such as are found in developing countries, mortality is higher.
- Also: Croup, myocarditis, pericarditis and disseminated intravascular coagulation (black measles).
- Subacute sclerosis panencephalitis (SSPE) occurs in 1 per 100,000 children with naturally occurring measles.
- After an incubation period of several years (mean 10.8), a progressive encephalopathy develops among unvaccinated children.
- Patients with SSPE are not infectious.
Measles - bibliography
American Academy of Pediatrics. Measles. In: Pickering LK, Baker CJ, Long SS, et al. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:441–452.
Atkinson W, Wolfe C, Humiston S, et al, eds. Epidemiology and Prevention of Vaccine Preventable Diseases. 6th ed. Department of Health & Human Services, Public Health Foundation; 2000.
- Bell LM. Update on measles. Cortlandt Forum. 1993;6:131–134.
- Duke T, Mgone CS. Measles: Not just another viral exanthema. Lancet. 2003;361:763–773.
- Farizo KM, Stehr-Green PA, Simpsons DM, et al. Pediatric emergency room visits: A risk factor for acquiring measles. Pediatrics. 1991;98:74.
- Huiming Y, Chaomin W, Meng M. Vitamin A for treating measles in children. Cochrane Database System Rev. 2005;CD001479.
- Hussey GD, Klein M. A randomized controlled trial of vitamin A in children with measles. N Engl J Med. 1990;323:169.
- Papania MJ, Seward JF, Redd SB, et al. Epidemiology of Measles in the United States, 1997–2001. J Infect Dis. 2004;189(Suppl 1):S61–S68.
- Perry RT, Halsey NA. The clinical significance of measles: A review. J Infect Dis. 2004;189(Suppl 1):S4–S16.
- Rall GF. Measles virus 1998–2002: Progress and controversy. Annu Rev Microbiol. 2003;57:343–367.
Measles - CODES
Measles - icd9
056.9 Measles
Measles - PATIENT TEACHING-MED
Educate on need for immunization
Measles - FAQ
- Q: If a health care worker has had a natural measles infection or measles immunization, should one be concerned about infection following exposure?
- A: Those persons born before 1957 who had a “wild measles virus” infection are usually immune from reinfection. However, in a report in 1993, 4 health care workers who were previously vaccinated with positive preillness measles antibody levels developed modified measles following exposure to infected patients. Therefore, all health care workers should observe respiratory precautions in caring for patients with measles.
- Q: During an outbreak of measles, should children younger than 12 months of age be vaccinated?
- A: In an outbreak of measles, public health officials may recommend vaccination of infants ages 6–11 months with a single-antigen measles vaccine; children initially vaccinated before their 1st birthday should be revaccinated at 12–15 months of age. A 2nd dose should be administered during the early school years.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Measles
More Medical Textbooks Online about Measles
Review other book chapters online related to Measles:
Medical Books Excerpts
- Rubeola
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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