Measles

BY
MUDALIAR, KANNAAN ANANDASUNDAR
MUNDALE,MINAL VINOD
MUNUSAMY ,TAMILARASI
 • L.J.
General data • 1YEAR/FEMALE
• FILIPINO
• CATHOLIC
• PUROK 18 CROSSING MALAGAMOT,
PANACAN, DAVAO CITY
• DATE OF ADMISSION: 12 APRIL 2019
• INFORMANT: MOTHER
• RELIABILITY: 85
Chief complaint:
RASHES
 • 6 DAYS PTC
HISTORY OF PRESENT
ILLNESS • (+) UNDOCUMENTED FEVER
NO CONSULT DONE , NO
MEDICATION GIVEN.

• 2 DAYS PTC
(+)NON PRODUCTIVE COUGH
(+)RASHES ON ABDOMEN NO
CONSULT DONE,NO MEDICATION
GIVEN
ON THE DAY OF CONSULTATION
• SYMPTOMS PERSISTED, HENCE SOUGHT
CONSULTATION IN ER
 • NOT ASTHMATIC
Past medical history • NO PREVIOUS HOSPITALIZATIONS
• NO PREVIOUS SURGICAL OPERATIONS
• NO KNOWN FOOD OR DRUG
ALLERGIES
• COMPLETE IMMUNIZATION STATUS (at
local health center)
• BCG, HEP B AT BIRTH
• AT 6, 10, 14 WEEKS – OPV,
PENTAVALENT
• AT 5 MONTHS – OPV BOOSTER AND
DPT BOOSTER
• NO MEASLES VACCINE
 • PRENATAL
Personal History • BORN TO A G4P4 27 YO MOTHER
• PATIENT’S MOTHER HAD REGULAR PRENATAL
CHECK-UPS.
• NO PRENATAL COMPLICATIONS

• BIRTH
• DELIVERED VIA NSVD AT SPMC
• NO CYANOSIS OR JAUNDICE AS CLAIMED
• BIRTHWEIGHT UNRECALLED
• APGAR SCORE UNRECALLED
 • NEONATAL
• NO NEWBORN SCREENING
• EXCLUSIVE BREASTFEEDING
Personal History
• GROWTH AND DEVELOPMENT
• ROLLS OVER - 4-5 MONTHS
• CRAWLING – 4 MONTH
• SIT STRAIGHT - 6MONTHS
• THUMB-FINGER GRASP-8
MONTHS
Family HISTORY
• (-) Measles exposure
• (-) Hypertension
• (-) Diabetes Mellitus
• (-) Bronchial Asthma
• (-) Thyroid disorders
• (-) Cancer
• (-) TB exposure
 • Family’s breadwinner:
Social condition patient’s father (labor)
• Family’s care taker: Patient’s
mother

• Mother house wife

• Lives with parents

 • General: (+) fever, (-) weight loss, (-)
anorexia
• Respiratory: (+) nonproductive
Review of systems cough, (-) dyspnea, (-) hemoptysis,
(-) breathlessness, (-) sputum
production, (-) wheezing
• Cardiac: (-) chest discomfort, (-)
orthopnea, (-) syncope, (-)
hypertension, (-) palpitations
• Gastrointestinal: (-) nausea, (-
)vomiting, (-) epigastric pain (-)
belching, (-) hematemesis, (-)
change of bowel habits, (-) melena,
(-) hematochezia
 • Musculoskeletal: (-) joint stiffness,
(-) joint pain, (-) back pain, (-)
Review of systems wasting, (-) scoliosis, (-) lordosis,
Extrimities:(+) maculopapular
rashes

• Endocrine: (-) heat/cold

intolerance, (-) polyphagia, (-)
polydipsia (-) polyuria
• Genito-urinary: (-) dysuria, (-)
hematuria, (-) urinary frequency, (-)
oliguria, (-) incontinence, (-)
nocturia,
• CNS: (-) headache (-) changes in
sensorium (-) weakness (-)
paresthesias
 • General Survey
Physical examination
• Awake, not in respiratory
distress
• Vital SignsPulse Rate: 142bpm
• Respiratory Rate: 28cpm
• Temperature: 36.9°
• O2 Sat (room air): 99%

• Anthropometrics
weight-7.4 kg
height-74cm
 • Skin, Hair, Nails: skin is moist and warm
with good turgor and mobility; hair is
Physical examination fine and black in color; (+)
maculopapular rashes generalized
• Head: no deformities, no lesions
• Eyes: not sunken eyeballs, pupil is equal,
round & reactive to light &
accomodation, anicteric sclera, pink
palpebral conjunctiva
• Ears: no ear discharges, lesions or
tenderness
• Nose: nasal septum midline,(-) nasal
congestion, (-) nasal flaring , no
epistaxis
• Mouth: Lips, buccal mucosa and tongue
are moist and pink in appearance
 • Throat & Neck: non-erythematous and non-
exudative tonsils, no palpable neck mass, no
Physical examination enlarged lymph nodes, no distended neck
veins
• Chest & Lungs: symmetrical and smooth
chest, breathing pattern even and regular,
equal chest expansion,(-)clear breath sound
• Cardiovascular: Adynamic precordium with
distinct heart sounds (S1 and S2), no murmur,
no palpitations
• abdomen: Globular, normoactive bowel
sounds, soft, nontender, no palpable mass,
no organomegaly, presence of
maculopapular rashes
• DRE: Not performed
• Musculoskeletal: no deformities, no edema,
limited range of motions
Physical examination • Alert
• CN I: Not performed
• CN II, III: (+) PLR
• CN III, IV, VI: intact extraocular movements
• CN V: (+) corneal reflex
• CN VII: no facial asymmetry
• CN VIII: Not performed
• CN IX, X: Not performed
• CN XI: Not performed
• CN XII: tongue at midline with no deviation

• Motor Strength: Not performed

• Sensory: Not performed
• Reflexes: Not performed
Salient features HISTORY
• nonproductive cough • Rashes spreading
• Undocumented fever cephalo-caudally
• 1year/ female

Physical exam
• Afebrile
• Maculopapular
rashes
• Non productive
cough
Admitting impression:
Measles pneumonia
Differential diagnosis • KAWASAKI DISEASE
• DENGUE FEVER
• RUBELLA
 Five principal clinical criteria of KD
KAWASAKI DISEASE • Bilateral nonexudative bulbar
conjunctival injection with limbal
sparing;
• Erythema of the oral and pharyngeal
mucosa with strawberry tongue and dry,
• Cracked lips;
• Edema and erythema of the hands and
feet;
• Rash of various forms (maculopapular,
erythema multiforme, or scarlatiniform)
with accentuation in the groin area;
• Nonsuppurative cervical
lymphadenopathy, usually unilateral
 RULE IN RULE OUT

• Fever • No cervical
• Maculopapular Rash Lymphadenopathy
• No Strawberry tongue
• Cephalocaudal spread of Rash
 • The clinical manifestations are variable
and are influenced by the age of the
patient.
• In infants and young children, the disease
may be undifferentiated or characterized
by fever for 1-5 days, pharyngeal
inflammation, rhinitis, and mild cough.
Dengue Fever • A transient, macular, generalized rash
that blanches under pressure may be
seen during the 1st 24-48 hr of fever
• From the 2nd to 6th day of fever,
nausea and vomiting are apt to occur,
and generalized lymphadenopathy,
cutaneous hyperesthesia or
hyperalgesia, taste aberrations, and
pronounced anorexia may develop.
 RULE IN RULE OUT

• Fever • No Lymphadenopathy
• Nonproductive • No episodes of Nose bleeds
Cough • Early onset Rash
• No Myalgia
• No vomiting
 • Low-grade fever, sore throat, red eyes with
or without eye pain, headache, malaise,
anorexia, and lymphadenopathy begins.
• In children, the 1st manifestation of rubella
is usually the rash, which is variable and not
distinctive.
• Rash spreads centrifugally to involve the
RUBELLA torso and extremities, where it tends to
occur as discrete macules.
• Examination of the oropharynx may reveal
tiny, rose-colored lesions ( Forchheimer
spots ) or petechial hemorrhages on the soft
palate.
• The duration of the rash is generally 3 days,
and it usually resolves without
desquamation.
 RULE IN RULE OUT

• Macular rash generalised • No lymphadenopathy

• Fever • Cephalocaudal spread of rashes
• No malaise
• No Forchheimer spots
• Measles Exposure
Clinical impression
MEASLES PNEUMONIA
Laboratory results

CBC

WBC 9.11

Neutrophil 15 (L)

Lymphocytes 75 (H)

Monocytes 10

Eosinophil 0 (L)

Hbg 119 (L)

Hct 0.36 (L)

RBC 4.69

Plt 435 (H)

 Final diagnosis:
MEASLES PNEUMONIA
Discussion
 Measles

Measles is a highly contagious

viral disease
Characterized by a prodromal
illness of fever, cough, coryza,
and conjunctivitis followed by
the appearance of a
generalized maculopapular
rash.
  Measles virus is a single-stranded,
lipid-enveloped RNA virus in the family
Paramyxoviridae and genus
Morbillivirus
ETIOLOGY
Humans are the only host of measles
virus
Of the 6 major structural proteins of
measles virus, the 2 most important in
terms of induction of immunity are the
hemagglutinin (H) protein and the
fusion (F) protein.
The neutralizing antibodies are
directed against the H protein, and
antibodies to the F protein limit
proliferation of the virus during
infection.
 In 2014 the Philippines experienced a large
measles outbreak. According to the World
Epidemiology Health Organization there were 57,564
suspected cases of measles, including 21,403
confirmed cases, and 110 measles deaths
reported in the Philippines from January 1
through December 20, 2014.
 Most of the cases were among unvaccinated
people.
A major outbreak was declared on February 6,
2019, with 70 recorded deaths of children
  The portal of entry of measles
virus is through the respiratory
TRANSMISSION tract or conjunctivae following
contact with large droplets or
small-droplet aerosols in which
the virus is suspended.
Patients are infectious from 3
days before to up to 4-6 days after
the onset of rash.
Face-to-face contact is not
necessary, because viable virus
may be suspended in air for as
long as 1 hr after the patient
with the source case leaves a
room
Pathology
• Necrosis of respiratory
epithelium
• Histology of Rash reveals
Edema and dyskeratosis
associated with formation of
Giant cells
• Lymphoid hyperplasia
• Warthin-Finkeldey Giant cells
 Measles consists of 4 phases
Incubation period,
Prodromal illness,
Pathogenesis Exanthematous phase,
Recovery
During incubation, measles virus migrates
to regional lymph nodes. A primary viremia
ensues that disseminates the virus to the
reticuloendothelial system. A secondary
viremia spreads virus to body surfaces.
The prodromal illness begins after the
secondary viremia and is associated with
epithelial necrosis and giant cell formation in
body tissues.
 Clinical Manifestations
 Fever and malaise beginning ~10
days after exposure are followed by
cough, coryza, and conjunctivitis.
These signs and symptoms increase
in severity over 4 days.
Headache, abdominal pain,
vomiting, diarrhea, and myalgia
may be present
 Buccal involvement
 Koplik’s spots are
pathognomonic of measles
and consist of bluish white
dots ~1 mm in diameter
surrounded by erythema.
 The lesions appear first on the
buccal mucosa opposite the
lower molars but rapidly
increase in number to involve
the entire buccal mucosa.
 They fade with the onset of
rash.
 Skin involvement
 Symptoms increase in intensity for 2-
4 days until the 1st day of the rash.
 The rash begins on the forehead
(around the hairline), behind the ears,
and on the upper neck as a red
maculopapular eruption.
 It then spreads downward to the
torso and extremities, reaching the
palms and soles in up to 50% of cases.
The exanthem frequently becomes
confluent on the face and upper trunk
 Measles is readily diagnosed on clinical
grounds by clinicians familiar with the
disease, particularly during outbreaks.
The CDC case definition for measles
requires
Diagnosis 1) A generalized maculopapular rash of
at least 3 days’ duration;
2) Fever of at least 38.3°C (101°F);
Measles virus–specific IgM 3) Cough, coryza, or conjunctivitis.
antibodies may not be
detectable until 4–5 days or Serology is the most common method of
more after rash onset laboratory diagnosis. The detection of
measles virus–specific IgM in a single
specimen of serum or oral fluid is
considered diagnostic of acute infection
  Pneumonia is the most common
cause of death in measles. It may
COMPLICATIONS manifest as giant cell pneumonia
caused directly by the viral infection or
as superimposed bacterial infection.
The most common bacterial
pathogens are Streptococcus
pneumoniae, Haemophilus influenzae,
and Staphylococcus aureus .
Following severe measles pneumonia,
the final common pathway to a fatal
outcome is often the development of
bronchiolitis obliterans

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  Measles encephalitis in
immunocompromised patients results
COMPLICATIONS from direct damage to the brain by the
virus.
Subacute measles encephalitis
manifests 1-10 months after measles in
immunocompromised patients,
particularly those with AIDS,
lymphoreticular malignancies, and
immunosuppression.
Signs and symptoms include seizures,
myoclonus, stupor, and coma.
In addition to intracellular inclusions,
abundant viral nucleocapsids and viral
antigen are seen in brain tissue.
Progressive disease and death almost
always occur.
 TREATMENT

•SUPPORTIVE
Hydration, Oxygenation, and Comfort are goals of
therapy.
Antipyretics for comfort and fever control are useful.
For patients with respiratory tract involvement, airway
humidification and supplemental oxygen may be of
benefit
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 TREATMENT
Vitamin A deficiency in children in developing countries has
long been known to be associated with increased mortality
from a variety of infectious diseases, including measles.
The American Academy of Pediatrics suggests vitamin A
therapy for selected patients with measles

2019/4/21
 Most persons with measles
PROGNOSIS recover and develop long-term
protective immunity to
reinfection.
Measles case-fatality proportions
vary with the average age of
infection, the nutritional and
immunologic status of the
population, measles vaccine
coverage, and access to health
care.

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PREVENTION Follow immunization
schedule of the country
10 months measles
14 months MMR
Followed by 2 doses
MMR
MMR booster during the
outbreak

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 THANK YOU!

2019/4/21