Rosen & Barkin's 5-Minute Emergency Medicine Consult (441 page)

• Vaccine preventable, primarily childhood, infectious disease characterized by fever, cough, coryza, conjunctivitis, and erythematous maculopapular rash
  
• Also known as rubeola
  
• Incidence is low secondary to widespread immunization
  

• Rubeola is a
  morbillivirus
  , a negative-strand (RNA) paramyxovirus
  
• Humans are the only known reservoir
  
• Highly contagious. Respiratory isolation should be initiated when suspected. Outbreaks seen in nonimmunized or underimmunized
  

• Increased risk of spontaneous abortion and premature contractions if infected during pregnancy.
  
• Does not appear to cause birth defects.
  
• Women should not be vaccinated with MMR or MMRV during pregnancy.
  

Those born before 1957 are generally considered immune. However, those in health care should receive vaccination if serologic testing reveals negative titer.

• Measles, mumps, and rubella ± Varicella (MMR or MMRV) vaccine should be administered to children on or after 12 mo of age. A 2nd dose is administered at the age of 4–6 yr, before start of school.
  
• Catch-up doses should be separated by at least 4 wk between vaccinations.
  

DIAGNOSIS

• Incubation (10–12 days) before appearance of rash:
  
  • Transmission via direct contact or inhalation of infectious droplet
    
  • Children usually have incomplete or no immunization.
    
• Prodrome (1–7 days):
  
  • Fever, followed by mild respiratory illness, conjunctivitis, fever
    
  • Koplik spots:
    
    • Small white to grayish-blue specks on buccal mucosa
      
    • Pathognomonic for rubeola
      
    • Transient. Appears 1–2 days before rash and disappears within 48 hr after onset of rash
      
• Active disease:
  
  • Cough, coryza, conjunctivitis (“three C’s”).
    
  • Fever of 101°F, usually higher. Fever beyond 3–4 days suggests measles related complication
    
  • Rash appears on day 3–7, lasting 4–7 days:
    
    • Begins on head and spreads centrifugally downward
      
    • Maculopapular blanching rash which becomes confluent. May have petechiae. Palm and soles rarely involved.
      
    • Clinical improvement seen in 48 hr of appearance of rash
      
    • Rash clears in 3–4 days and may desquamate as rash fades in order of appearance
      
• Complications:
  
  • Respiratory:
    
    • Cough may persist for 1–2 wk after measles infection.
      
    • Pneumonia (6%) seen most commonly in immunocompromised
      
    • Most common cause of fatality seen with measles
      
    • Laryngotracheobronchitis in patients <2 yr old
      
  • CNS:
    
    • Seizures <1%
      
    • Encephalitis
      
    • Encephalomyelitis:
      
      • 1–14 days after onset of rash. Due to post infection autoimmune response
        
      • Fever, headache, vomiting, and stiff neck
        
      • Lethargy, stupor, and seizure followed by coma
        
    • Subacute sclerosing panencephalitis (SSPE):
      
      • Very rare but serious complication that develops 7–10 yr after infection
        
      • Insidiously progressive degeneration of CNS functions
        
      • Personality change, intellectual deterioration, motor and visual deficits, seizures, coma, and death
        
  • Cardiovascular:
    
    • Transient myocarditis, pericarditis, and conduction defects
      
    • Rarely clinically significant
      
    • Congestive heart failure in elderly patients
      
  • Thrombocytopenic purpura
    
  • Otitis media 7%
    
  • Sinusitis
    
  • Diarrhea 8%, most common
    

• Diagnosis is based on clinical findings.
  
• Cough, coryza, and conjunctivitis with fever and subsequent rash
  

• CSF analysis for suspected encephalitis
  
• Viral isolation from blood, throat, nasopharynx, and urine for epidemiologic surveillance. Ideally within 7 and not more than 10 days of appearance of rash.
  
• Serologic tests for measles IgM and IgG titers, and PCR of measles virus RNA are available to confirm diagnosis
  

Chest radiograph for suspected pneumonia

• Rubella
  
  • Milder course, postauricular nodes, pinker rash, no conjunctivitis
    
• Scarlet fever:
  
  • Sandpaper-textured rash, strawberry tongue, sore throat
    
• Infectious mononucleosis:
  
  • Serologic test available
    
• Roseola:
  
  • Rash appears after temperature falls.
    
• Erythema infectiosum (“fifth disease”):
  
  • No prodrome and without fever
    
  • Red, flushed cheeks with lace-like rash when fading
    
• Enterovirus:
  
  • No respiratory complaints
    
• Kawasaki disease:
  
  • Rash on palm and soles
    
• Secondary syphilis
  
• Toxic shock syndrome
  
• Drug reactions:
  
  • Usually without high fever and upper respiratory infection symptoms
    

TREATMENT

Nonimmunized pre-hospital care personnel should be advised of potential risks described above.

• ABCs if indicated
  

• Prevention with vaccination is cornerstone of therapy
  
• Antipyretics
  
• IV hydration if needed
  
• Isolate suspected cases
  
• Postexposure prophylaxis for the nonimmune:
  
  • Give MMR if <72 hr after exposure:
    
    • Avoid if pregnant or immunocompromised.
      
  • Immunoglobulin 0.25 mL/kg IM up to 15 mL (max.):
    
    • If given <6 days after exposure, may prevent or modify severity of symptoms
      
    • Indicated for susceptible household or other close contacts, particularly those <1 yr, pregnant women, or immunocompromised
      
    • For patients who receive immune globulin IV (IGIV) regularly, the usual dose of 400 mg/kg should be adequate for measles prophylaxis after exposure occurring within 3 wk of receiving IGIV.
      
    • Patients receiving IG should subsequently receive vaccine no sooner than 5–6 mo if not contraindicated.
      
• ABCs. Oxygenation and airway protection for:
  
  • Pneumonia
    
  • Encephalitis
    

WHO recommends vitamin A once in a day for 2 days for children with measles where vitamin A deficiency is prevalent. It may reduce the risk of measles mortality:

• 50,000 IU for age <6 mo
  
• 100,000 IU for age 6–12 mo
  
• 200,000 IU for age >12 mo
  
• Parenteral and oral formulations are available in US
  

FOLLOW-UP

• Severe pneumonia
  
• Dehydration
  
• Encephalitis
  
• SSPE
  
• Immunocompromised patients:
  
  • AIDS
    
  • Immunosuppressive therapy
    
• Elderly patients with comorbid conditions
  

Duration of infectivity:

• 4 days before symptoms and up to 4 days after onset of rash
  
• Immunocompromised are contagious for duration of illness
  

• One of the most highly communicable of infectious diseases; death occurs in 1–3/1,000 cases in US. Respiratory isolation in health care settings is a must
  
• Severely immunocompromised patients, those on immunotherapy, and pregnant patients should not receive MMR or MMRV vaccine.
  
• Characteristic rash may not develop in immunocompromised patients.
  

• American Academy of Pediatrics. Measles. In: Pickering LK, ed.
  Red Book 2012: The Report of the Committee on Infectious Diseases.
  27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:489–499.
  
• Centers for Disease Control and Prevention. Measles. In: Atkinson W, Wolfe S, Hamborsky J, eds.
  Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book)
  . 12th ed. Washington, DC: Public Health Foundation; 2012:173–192.
  
• Mason WH. Measles. In: Kliegman RM, ed.
  Nelson Textbook of Pediatrics
  , 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:1069–1075.
  

See Also (Topic, Algorithm, Electronic Media Element)

http://www.cdc.gov/measles

CODES