MEASLES

Fen Hua Chen, M.D.,PhD. Department of Pediatrics, The Third Affiliated Hospital Sun Yat-sen University Yat-

DEFINITION
Measles is
an acute viral infection characterized by a maculopapular rash erupting successively over the neck, face, body, and extremitis and accompanied by a high fever. fever.

ETIOLOGY
Measles virus
An RNA virus of the genus Morbillivirus in the family of Paramyxoviridae One serotype, humans only host Stable antigenicity Rapidly inactivated by heat and light Survival in low temperature.

EPIDEMIOLOGY PIDEMIOLOGY
Infection sources


Patients of acute stage and viral carriers of atypical measles Highly contagious, approximately 90% of susceptible contacts acquire the disease. Respiratory secretions: maximal dissemination of virus secretions: occurs by droplet spray during the prodromal period (catarrhal stage). Contagious from 5 days before symptoms, 5 days after symptoms, onset of rash Seasons: in the spring, peak in Feb-May Feb-

Transmission


PATHOGENESIS AND PATHOLOGY

Portal of entry
 

Respiratory tract and regional lymph nodes Enters bloodstream (primary viraemia) monocyte phagocyte system target organs (secondary viraemia) The skin; the mucous membranes of the nasopharynx, bronchi, and intestinal tract; and in the conjunctivae, ect conjunctivae,

Target organs


Resulting In----In----1) Koplik spots and skin rash: serous exudation and proliferation of endothelial cells around the capillaries 2) Conjunctivis

PATHOGENESIS AND PATHOLOGY

3) Laryngitis, croup, bronchitis :general inflammatory reaction 4) Hyperplasia of lymphoid tissue: multinucleated giant cells (Warthin(Warthin-Finkeldey giant cells) may be found 5) Interstitial pneumonitis: Hecht giant cell pneumonia. pneumonia. 6) Bronchopneumonia: due to secondary bacterial infections 7) Encephalomyelitis: perivascular demyelinization occurs in areas of the brain and spinal cord. 8) Subacute sclerosing panencephalitis(SSPE): degeneration of the cortex and white matter with intranuclear and intracytoplasmic inclusion bodies

CLINICAL MANIFESTATION
Typical Manifestation:
patients havnt had measles immunization, or vaccine failure with normal immunity or those havnt used immune globulin

1. Incubation period (infection to symptoms) :

6-18days (average 10 days)

2. Prodromal period:
 

3-4 days NonNon-specific symptoms: fever, malaise, anorexia, headache Classical triad: cough, coryza, conjunctivitis (with photophobia, lacrimation)

CLINICAL MANIFESTATION
Enanthem (Koplik spots):
  

 

Pathognomonic for measles 2424-48 hr before rash appears 1mm, grayish white dots with slight, reddish areolae Buccal mucosa, opposite the lower 2nd molars increase within 1day and spread fade soon after rash onset

CLINICAL MANIFESTATION

Koplik spots

CLINICAL MANIFESTATION
3. Rash period
3-4days

Exanthem:


Erythematous, non-pruritic, maculopapular nonUpper lateral of the neck, behind ears, hairline, face trunk arms and legs feet The severity of the disease is directly related to the extent and confluence of the rash

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION
Temperature:
  

Rises abruptly as the rash appears Reaches 40 or higher Settles after 4-5 days if persists, suspect secondary 4infection Coryza, fever, and cough: Increasingly severe up to the time the rash has covered the body

Lymphadenopathy (posterior cervical region, mesenteric) splenomegaly, diarrhoea, vomiting



Chest X ray: May be abnormal, even in uncomplicated cases

CLINICAL MANIFESTATION
4. Recovery period
3-4days Exanthem: Fades in order of appearance Branny desquamation and brownish discoloration Entire illness 10 days

 

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION
Atypical Manifestation:
1. Mild measles


    

In patients: administered immune globulin products during the incubation period and immunized against measles; in infants <8mo Long incubation period and short prodromal phase Mild symptom No Koplik spot The rash tends to be faint, less macular, pinpoint No branny desquamation and brownish discoloration occur as the rash fades No complications and short course

CLINICAL MANIFESTATION
2. Severe measles:


  

In cases with malnutrition, hypoimmunity and secondary infection Persistent hyperpyrexia, sometimes with convulsions and even coma Exanthem: Completely covered the skin Confluent, petechiae, ecchymoses The hemorrhagic type of measles (black measles), bleeding may occur from the mouth, nose, or bowel. disseminated intravascular coagulation (DIC)

CLINICAL MANIFESTATION

CLINICAL MANIFESTATION
3. Atypical measles syndroma:


 

Recipients of killed measles virus vaccine, who later come in contact with wild-type measles virus. wildDistinguished by high fever, severe headache, severe abdominal pain, often with vomiting, myalgias, respiratory symptoms, pneumonia with pleural effusion Exanthem: First appears on the palms, wrists, soles, and ankles, and progresses in a centripetal direction. Maculopapular vesicular purpuric or hemorrhagic. Koplik spots rarely appear

CLINICAL MANIFESTATION

Atypical measles syndroma

CLINICAL MANIFESTATION
4. Measles absent of rush


 

Immunodepressed, or passive immunized recently cases and occasionally in infants <9mo who have appreciable levels of maternal antibody NonNon-specificity Difficult to diagnosis

COMPLICATIONS
1. Respiratory Tract Laryngitis, tracheitis, bronchitis due to measles itself Laryngotrachobronchitis (croup) cause airway obstruction to require tracheostomy Secondary pneumonia immunocompromised, malnourished patients. pneumococcus, group A Streptococcus, Staphylococcus aureus and Haemophilus influenzae type B. Exacerbation of TB

COMPLICATIONS

2. Myocarditis 3. Malnutrition and Vitamin A deficiency

COMPLICATIONS
4. CNS
The incidence of encephalomyelitis is 1-2/l,000 cases of 1measles Onset occurs 2-5 days after the appearance of the rash 2No correlation between the severity of the rash illness and that of the neurologic involvement  Earlier - direct viral effect in CNS  Later immune response causing demyelination  Significant morbidity, permanent sequelae mental retardation and paralysis Subacute sclerosing panencephalitis (SSPE): extremely rare, 6-10 years after infection. Progressive dementia, fatal. Interaction of host with defective form of virus

LABORATORY EXAMINATION
Isolation of measles virus from a clinical specimen (e.g., nasopharynx, urine) Significant rise in measles IgG by any standard serologic assay Positive serologic test for measles IgM antibody Immunofluorescence detects Measles antigens Multinucleated giant cells in smears of nasal mucosa Low white blood cell count and a relative lymphocytosis in PB Measles encephalitis raised protein, lymphocytes in CSF

DIAGNOSIS
characteristic clinical picture:
Measles contact Koplik spot Features of the skin rash The relation between the eruption and fever Laboratory confirmation is rarely needed

DIFFERENTIAL DIAGNOSIS
The rash of measles must be differentiated from that of rubella; roseola intantum; enteroviral infections; scarlet fever; and drug rashes.

Pathogen
Measles Measles virus

Features
Cough coryza, conjunctivitis Koplik spot after the 2nd -3rd fever Disease is mild, postaupostauricular lymphadenopathy

Rash

fever Vs Rash

Rubella

Rubella virus

Roseola Infantum

Human herpesvirus 6

Scarlet fever Group A Streptococcus

Generally well, Seizures (5(5-10%) due to high fever High fever, toxicity, Angina, strawberry tongue Circumoral pallor, tonsillitis Accompanied by respiratory or gastrointestinal manifestation Manifestations of primary disease, itching

Enteroviral Infections

Echovirus, Coxsackievirus

Drug Rash

Red maculopapule fever for3-4days for3Face trunk limbs rises abruptly as Desquamation and the rash appears discoloration Maculopapule fever for1-2days for1Face trunk limbs low or absent No desquamation and during the rash discoloration Rose colored, spreads high fever for3-5 for3to the neck and the days, ceases with trunk the onset of rash Gooseflesh texture on fever for1-2days for1an erythematous base higher as the for 3-5 day, desquam3desquamrash appears ation after 1 week Scattered macule or Rash appears maculopapule, few during or after confluent, 1-3 days, 1fever no desquamation Urticarial, maculopapula Relates to the or scarlatiniform rash drugs taken

DIFFERENTIAL DIAGNOSIS

Scarlet fever

DIFFERENTIAL DIAGNOSIS

Scarlet fever

TREATMENT
Supportive, symptom-directed symptomAntipyretics for fever Bed rest Adequate fluid intake Be protected from exposure to strong light

Antibiotics for otitis media, pneumonia High doses Vitamin A in severe/ potentially severe measles/ patients less than 2 years
100,000IU 100,000IU200,000IU

PREVENTION
1. Quarantine period

5 days after rash appears, longer for complicated measles

2. Vaccine
The initial measles immunization is recommended at 8mo of age A second immunization is recommended routinely at 7yr of age

3. Postexposure Prophylaxis
Passive immunization with immune globulin (0.25mL/kg) is effective for prevention and attenuation of measles within 5 days of exposure.

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