General Data

Z.B.O.
11 months old
Female
EDD/PA
Roman Catholic
8 April 2014 (AFP Medical Center)
9 E. Ramos St., Krus na Ligas, Quezon City
Admitted for the 1st time at our institution.

History of Present Illness

12 days
PTA

(+) non-productive cough

(-) colds, fever or vomiting
with good suck & activity
Salbutamol nebulization
BID
Cetirizine at 0.11 mkdose
Slight relief

History of Present Illness

8 days
PTA

(+) non-productive cough

(-) colds, fever or vomiting
Consult with a private
pediatrician:
A> Bronchial Asthma
Ipratropium + Salbutamol
nebulization BID
Cetirizine at 0.11 mkdose
Slight relief

History of Present Illness

4 days
PTA

(+) non-productive cough

(+) fever of 37.9oC
(-) colds, vomiting or
rashes
with good suck and
activity
Paracetamol at 11
mkdose
temporary lysis of fever.

History of Present Illness

3 days
PTA

(+) non-productive cough

(+) on and off fever (TMax
37.8oC)
(-) colds, vomiting or rashes
with good suck and activity
Consult with the same
pediatrician
Assessment was undisclosed
Amoxicillin at 51 mkday
Paracetamol at 11 mkdose
slight relief of symptoms.

History of Present Illness

1 days
PTA

(+) non-productive cough

(+) on and off fever (TMax
39oC)
(+) colds
(+) maculopapular rashes
at periorbital area
with good suck and activity
Medications were continued
with slight relief of
symptoms.

History of Present Illness

Few hours
PTA

(+) non-productive
cough
(+) on and off fever
(TMax 37.8oC)
(+) generalized
maculopapular rashes
With good suck and
activity

History of Present Illness

Few hours
PTA

Consult with the same

pediatrician
A> Acute Viral Illness with
dehydration
CBC: Hgb 118, Hct 0.35, RBC
4.40, WBC 5.63, Seg .17, Lym
0.76, Mon 0.07, Plt 151
CRP: <6mg/dl (negative)
ESR: 13mm/hr [0-10mm/hr]
Advised admission but opted
to transfer to our institution

History of Present Illness

At the
Infecious
ward

Awake, irritable not in

distress
With watery eye discharge,
nasal discharge, dry lips,
Clear breath sounds
Full and equal pulses warm
With maculopapular rashes,
generalized CRT<2 sec
P> Admission

Pre-natal history
Cognizant of her pregnancy at 2 months
due to missed menstruation supported by a
positive pregnancy test
At 7 months AOG, mother had exacerbation
of Bronchial Asthma and was given
Salbutamol nebulization and Cefuroxime for
7 days
No other maternal Illness
Mother denies exposure to radiation nor
intake of teratogenic drugs.

Natal History
Born to a 37 year old G2P2 (2002) mother, term, via
LTCS II (CS I sec. to fetal distress) at AFP Medical
Center assisted by an obstetrician, AS 8,9, 39 weeks
by BS, BW 3.25 kg and unrecalled anthropometrics
Was able to pass urine and meconium with the first
24 hours of life
Phototherapy (Blue) for 2 days. Patient was
discharged after 3 days.
Newborn screening was done which showed
unremarkable results.
OAE was not done.

Immunization

BCG at birth
Hepa B 3 doses
DPT 3 doses
OPV 3 doses
Hib 3 doses
Measles 1 dose (January 27, 2015)

Feeding History
Birth 3 mos: exclusive breast
feeding per demand
3 months: NanPro 1/ Nan HW
7 months present: NanPro 2/Nan
HW
Given mashed broccoli which
resulted to pruritic rashes

Growth and Development

Social smile at 2 months
Rolls over at 4 months
Crawls at 5 months
Sits with support at 6 months
Stand with support at 11 months
At par with age.
At present, patient can stand with support,
Peek-a-boo, thumb finger grasps, and
imitate sounds

Past Medical History

Frequent consult due to cough and
colds
Bronchial Asthma (November 2014)
Allergic to broccoli, citrus, potato,
Neozep

Family Profile
Father, 39 years old, SSG/PA,
apparently well
Mother, 37 years old, college
graduate, currently a housewife,
Bronchial asthma
G1, 2 years old, female, apparently
well
G2 index patient

Social and Environment History

Lives in a 2-storey house

Well-lit and well ventilated
3 bedrooms and 2 comfort room
11 other family members
Source of drinking water is mineral
water
No measles in the community

Physical Examination

awake, irritable, not in distress

HR:126, RR:26, Temp: 37.4C
Wt: 8.7 kg, Lt: 70 cm
HC: 45 CC: 44, AC 42
BSA: 0.41

 warm skin, dry, good skin turgor, CRT

< 2secs maculopapular rashes
generalized
anicteric sclerae, pink palpebral
conjunctiva,(+) slightly sunken
eyeball, watery eye discharge, dry
lips, moist buccal mucosa, (-) nonhyperemic tonsils, (+) cervical
lymphadenopathy 0.5x0.5cm, left,
post-auricular

 Symmetrical chest expansion, no

retractions, clear breath sounds
Adynamic precordium, normal rate,
regular rhythm, no murmur
Flat, normoactive bowel sounds, soft,
non-tender
Grossly female
full and equal pulses

Salient Features
Z.B.O.
11 months/female
Maculopapular rash Periorbital area
generalized rash
Low grade fever
Non-productive cough
No colds, vomiting,
diarrhea

Awake, irritable, not in

distress
HR 126, RR 26, Temp
37.4
Generalized
maculopapular rash
Slightly sunken
eyeball, watery eye
discharge, dry lips,
moist buccal mucosa
Cervical
lymphadenopathy
0.5x0.5cm, left,
postauricular

Measles (Rubeola)
Etiology

Paramyxovirida
e

Incubati
on

10-12 days

Epidem

All ages

Rash

Maculopapular

Spread

Face, rapidly
spreads

Prodrome

3-5 days
Low-moderate fever, hacking
cough, coryza, conjunctivitis,
Koplik spots after 2-3 days

Fever

High T abruptly as rash

appears Low T when rash
reaches legs/feet

Infectious
Period

Isolate 7th day post

exposure, until 5 day after
rash appeared.

Rash

Lateral neck, ears, hairline to

back, abdomen thigh..feet
on 2nd day

Desquamati Branny desquamation

on
(Brownish discoloration)

Rubella (German Measles)

Etiology

Togaviridae

Prodrome

Incubati
on

14- 21 days

Fever

Epidem

6-18 mos. old

Infectious
Period

Rash

Maculopapular

Rash

Mild catarrhal retoauricular,

post cervical
lymphadenopathy
Sudden onset Increase T
Decrease T on 3rd 4th day as
rashes appear.
9th 10th days post exposure
(peak)
Absence of P.E. finding to
explain fever
Trunk & Extermities

Spread

Trunk to the
Desquamati Minimal desquamation
arms,
on
neck,face,legs
3 days

Blueberry Muffin Lesions

Roseola Infantum
Etiology

HHV 6 & 7

Prodrome

None

Incubati
on

7-17 days

Fever

Epidem

6-36 mos

Infectious
Period

Rash

Maculopapul
ar

Rash

Spread

Lasts for 24
hours

Desquama Rare
tion

Absent or low grade

Rash starts from the trunk

and spreads to the neck,
face
and proximal extremities

Nagayama spots

Erythema Infectiosum
Etiology

Parvovirus B19

Prodrome

Incubati
on

7-28 days

Epidem

Rarely > 3y/o

Infectious
Period

Rash

Maculopapular

Rash

Fever

Low-grade fever, headache,

mild upper respiratory
Symptoms
Joint symptoms common in
older adolescents & adults.
esp women
Low grade
3rd day of fever & 1st day of
rash
Red, flushed cheeks with
circumoral pallor (slapped
cheek appearance
Maculopapular eruption over
upper and lower extremities
(the rash assumes a lacelike
appearance
as it fades)

Kawasakis
Etiology

Unknown
(infectious)

Incubati
on

Fever

Epidem

<5 years old

Rash

Maculopapular

Spread

Prodrome

Bilateral conjunctival injection

(without exudate,)
Unilateral CLAD
Remittent
Spiking > 5days

Infectious
Period
Rash

Generalized, erythematous,
maculopapular. The palms
and soles are swollen and
reddened, eventually peeling
after several days or weeks.

Desquamati Periungal or Perianal

on
desquamation

Non-exudative
Conjunctivitis

Edema and Rash

Periungal desquamation

Admission
Assessment: Measles with moderate signs of
dehydration
Plan:
CBC with QPC
Chest X-ray (APLat)
Measles IgG, IgM
IVF D5 0.3 NaCl 440ml at 73-74 ml/hr for 6 hours
Paracetamol 100mg/ml 0.9ml every 4 hours
Isoniazid 200mg/5ml 2 ml once a day for 3 months
Vitamin A 100,000 PO once a day for 2 days
Multivitamins 1 ml once a day

Admission
Plan:
CBC with QPC
Chest X-ray (APLat)
Measles IgG, IgM
IVF D5 0.3 NaCl 440ml at 73-74 ml/hr for 6 hours
Paracetamol 100mg/ml 0.9ml every 4 hours
Isoniazid 200mg/5ml 2 ml once a day for 3
months
Vitamin A 100,000 PO once a day for 2 days
Multivitamins 1 ml once a day

Laboratory
CBC
Hgb
Hct
RBC
WBC
Segmenters
Lymphocytes
Eosinophils
Monocytes
Platelet count

13 Mar 15
127
0.36
4.67
6.06
0.11
0.82
0.00
0.06
117

Course in the Ward: 14 Mar

15
S/O> (-) fever (LFE: 13 Mar 15 1600H 37.8C)
(+) maculopapular rash
(+) cough/ colds
(+) watery eye discharge
fair appetite, fair activity
A/P> VS HR 126, RR 26, Temp 36.1
D5 IMB 870ml at 48-49ml/hr for 18 hours
Cetirizine 1mg/ml 2 ml OD for pruritus

Course in the Ward: 15 Mar

15
S/O> (-) fever
(+) maculopapular rash
(+) cough/ colds
(+) watery eye discharge
fair to good appetite and activity
A/P> VS HR 126, RR 26, Temp 36.1
D5 IMB 450ml at 18-19ml/hr for 24 hours

Course in the Ward: 16 Mar

15
S/O> (-) fever
(+) decreased maculopapular rash
(+) occasional cough
(-) watery eye discharge
good appetite, good activity
A/P> VS HR 121, RR 28, Temp 36.7,
Wt 8.6 kg
MGH

Measles

Etiology
Single-stranded lipid enveloped RNA
virus (Paramyxoviridae - Morbilivirus)
6 major structural proteins:
induction of immunity are the
hemagglutinin (H) protein and the
fusion (F) protein.
Antibodies towards these proteins limit
proliferation of the virus

Epidemiology
Measles vaccine has changed the
epidemiology of measles
dramatically
1/1,000,000
Vaccine failure occurs in as many as
5% of people who have received a
single dose of vaccine at 12 months
or older

Transmission
Droplet spray during the prodromal
period (highly contagious)
Infectious: 3 days before the rash up to
4-6 days after onset

Enters through respiratory tract or

conjunctivae following contact with
large or small droplet aerosols in
which the virus is suspended

Pathology
It causes necrosis of the respiratory
epithelium and an accompanying
lymphocytic infiltrate
Produces small cell vasculitis on the skin
and on the oral mucous membranes.
Histopathology of the rash & exanthem
intracellular edema & dyskeratosis
associated with formation of epidermal
syncytial giant cells

Pathogenesis
FOUR PHASES:
1. Incubation Phase (8-12 days)
. Virus migrate to regional lymph nodes
Primary viremia disseminates the virus
to the reticuloendothelial system.
Secondary viremia virus spread to the
body surfaces.

Pathogenesis
2. Prodromal Illness (3-5 days)
Associated with epithelial necrosis
and giant cell formation in the body
Associated with viral replication that
occurs in many body tissues,
including cells of the CNS
virus shedding begins

Pathogenesis
3. Enanthem
Koplik spots
First appear as discrete red lesions with bluish
white spots in the center on theinner aspect of
the cheeks at the level of premolars
May appear in conjunctival folds and vaginal
mucosa
Seen in 50-70% of measles
Appears 1-4 days prior to the onset of rash.

Signs and Symptoms

Conjunctivitis with photophobia
Brownish discoloration & branny
desquamation
Coryza
Prominent cough
Increasing fever
Lympadenopathy

4. Recovery
Onset of rash, symptoms begin to
subside and the rash fades over
about 7 days in the same progression
as it evolved, often leaving a fine
desquamation of skin in its wake.
Of the major symptoms of measles,
cough last longer (up to 10 days)

Modified Measles
An attenuated form of infection that
may occur in individuals who have
received immune globulin after
exposure to measles
The clinical manifestations are milder
than those of typical infection, and the
incubation period is prolonged from
14 to 20 days.

Atypical Measles
Occurs in individuals infected with natural virus
and who previously received killed measles
vaccines
Sudden onset of high fever accompanied by
abdominal pain, cough, vomiting, and pleuritic
chest pain
Koplik spots are rarely present, and rash begins
distally and progresses in a cephalad direction,
with little involvement of the face and upper
part of the trunk

DIAGNOSTICS
Serology for IgM
Viral specimen (nasopharyngeal,
oropharyngeal, or nasal swab) for
PCR (and genotyping)
Acute and convalescent specimens
for IgG may be useful, especially in
vaccinated cases

TREATMENT
SUPPORTIVE CARE:
1. Maintenance of good hydration and
replacement of fluids lost through
diarrhea or vomiting
IV rehydration may be necessary for
severe dehydration
Affected patients may be highly febrile
and consequently become dehydrated

TREATMENT
2. Continue breastfeeding and
continue feeding for older infants and
children
3. Antipyretics for fever at 10-15
mg/kg/dose given every 4 hours for
feveR

TREATMENT
4. Airborne precautions for hospitalized
children during the period of communicability,
4 days before to 4 days after the
appearance of the rash in healthy children
and for the duration of illness in
immunocompromised patients.
5. Among susceptible health care workers,
they should be excused from work from the
fifth to the 21st day after exposure

TREATMENT
Treat children with severe measles (e.g.
hospitalized) with vitamin A
Administer vitamin A immediately on diagnosis
and repeat the next day. The recommended
age-specific daily doses are
o 50 000 IU for infants aged <6 months
o 100 000 IU for infants aged 611 months
o 200 000 IU for children aged 12 month

Give Isoniazid at 10mkd

ANTI-VIRAL THERAPY
No specific antiviral therapy is available.
Measles virus is susceptible in vitro to
ribavirin, which has been given by the
intravenous and aerosol routes to treat
severely affected and immunocompromised
children with measles. However, no
controlled trials have been conducted, and
ribavirin is not approved by the US Food and
Drug Administration for treatment of
measles. Thus, this is NOT recommended.

Isolation
In addition to standard precautions, airborne
transmission precautions are indicated for 4
days after the onset of rash in otherwise
healthy children and for the duration of
illness in immunocompromised patients.
Exposed susceptible patients should be
placed on airborne precautions from day 5
after first exposure until day 21 after last
exposure.

VACCINATION
Monovalent or trivalent vaccine
(contains measles, mumps and
rubella).
A tetravalent vaccine, MMRV
(contains measles, mumps, rubella
and varicella) may be used for
infants 12 months to 12 years of age

Age of Routine
Immunization
The first dose of MMR vaccine should be
given at 12 through 15 months of age.
The second dose is recommended routinely
at school entry (ie, 4 through 6 years of
age) but can be given at any earlier age
(eg, during an outbreak or before
international travel), provided the interval
between the first and second MMR doses is
at least 28 days.

Age of Routine
Immunization
Catch-up second dose immunization should occur
for all school children (elementary, middle, high
school) who have received only 1 dose, including
at the adolescent visit at 11 through 12 years of
age and beyond.
If a child receives a dose of measles vaccine before
12 months of age, this dose is not counted toward
the required number of doses, and 2 additional
doses are required beginning at 12 through 15
months of age and separated by at least 28 days.

VACCINATION
A temperature of 39.4C (103F) or higher
develops in approximately 5% to 15% of
vaccine recipients, usually between 6 and
12 days after receipt of MMR vaccine;
fever generally lasts 1 to 2 days but may
last as long as 5 days.
Transient rashes have been reported in
approximately 5% of vaccine recipients.

VACCINATION
Recipients who develop fever and/or rash are
not considered contagious.
Febrile seizures 5 to 12 days after
immunization occur in 1 in 3000 to 4000
people immunized with MMR vaccine.
Transient thrombocytopenia occurs in 1 in 22
000 to 40 000 people after administration of
measles-containing vaccines, specifically MMR

Complications
Attributed to the pathogenic effects of the
virus on the respiratory tract and immune
system
Morbidity & mortality: < 5 yrs of age
(especially < 1 yr of age) and those > 20
yrs of age.
Higher fatality: crowding, household exposure
Malnutrition
Low serum retinol levels

Complications
1. Pneumonia
. Most common cause of death in measles.
Most common pathogens:
- S. pneumoniae, H. influenzae, S. aureus

2. Croup, tracheitis, bronchiolitis

. Common complications in infants & todders.
(intubation & ventilatory support)

Complications
3. Acute Otitis Media
Most common complication of measles
4. Increase Activation of Pulmonary Tuberculosis
Measles suppress skin test to purified Tuberculin
antigen
5. Diarrhea & Vomiting
6. Lymphoid Hyperplasia
appendicitis may occur due to obstruction of the lumen

Complications
7. Subacute Measles Encephalitis
Immunocompromised patients
8. Myocarditis
9. Febrile seizures
< 3% (post infection: seizure (56%), lethargy
(46%), coma (28%) and irritability (26%).

CSF: lymphocytic pleocytosis (85%) & elevated

protein concentration.

Complications
10. SSPE (subacute sclerosing parencephalitis)
Chronic complication of measles with a delayed
onset and an outcome nearly fatal.
Persistent infection with an altered measles virus
harbored intracellularly CNS for years.
7 to 10 years: virus regains virulence & attacks.

Prognosis
Mortality: 10/1000 case of Measles in
the early 20th centurey
1/10000

Background
Research efforts concerning
identification of factors potentially
associated with waning of measles
vaccine virus-specific antibody are
limited
This concern becomes especially
relevant considering that asthma has
been reported to be associated with an
increased risk of microbial infections

 Determine whether asthma status

affects waning of adaptive immunity
Hypothesized that asthmatics have a
more rapid waning of measles
antibody than non-asthmatics

Methods
The study used a cross-sectional
cohort of healthy children residing in
Olmsted County, MN who had been
enrolled in a previous vaccine study.
The original study was designed to
examine seroprevalence of measles
vaccine virus-specific antibody in
1993

 Original study cohort (n = 876) included

healthy children, ages 512 years, who had
been immunized with 1 dose of MMR-II vaccine
at approximately age 15 months between
1981 and 1992
This second study included 838 eligible
subjects from the original study cohort (n =
876) after excluding 38 subjects (n = 24 for no
research authorization for additional research
studies and n = 14 for insufficient information
for determining asthma Status)

 The mean (SD) age at index date for

asthma was 8.1 (5.1) years based on
all 281 asthmatics

Results
Of the 838 eligible children, 281 (34%) met criteria
for asthma. Measles antibody waned over time (r =
0.19, P < 0.001), specifically more rapidly in
asthmatics (r = 0.30, P < 0.001, a decrease of
0.114 unit per year) than nonasthmatics (r = 0.13,
P = 0.002, a decrease of 0.046 unit per year; P
value for interaction = 0.010). This differential waning
rate resulted in a lower mean (SD) measles antibody
concentration [1.42 (0.67) vs. 1.67 (0.69), P = 0.008]
and lower seropositivity rate (73% vs. 84%, P =
0.038) in asthmatics than nonasthmatics starting
around 9.3 years after the initial measles vaccination.

 Overall, asthma is associated with a

more rapid waning of measles
antibody leading to a lower
seropositivity of measles antibody
among asthmatics than nonasthmatics

Conclusion
In conclusion, asthma status is
associated with waning of measles
antibody among children and this
influence takes place before onset of
clinical asthma.