MEASLES

Rubeola

dr.p.natarajan
 Epidemiology
• Most infectious viruses known to man.
• Rarely will an un-immunized child escape.
• Responsible for more deaths than any other
single agent.
• Median case fatality ratio of 3.7%, range 0 to
23.9%.
• Vaccine from 1963 changed the epidemiology.
• Incidence rate: up to140 per 100,000
population
 Aetiology:

• Single stranded RNA

with lipid envelope
• Genus: morbilivirus;
family:
paramyxoviridae
• Human are the only
host
 Transmission & Pathology
• By droplets through respiratory mucosa and rarely
conjunctiva.
• Infective period: 3 days before and 5 days after rashes
appear.
• Necrosis of respiratory epithelium
• Lymphocytic infiltration
• Small vessel vasculitis of skin and mucosa
• giant cells (up to 26 nuclei)
• Fused cells with more than 100 nuclei called Warthin-
Finkaldey giant cells
 Pathogenesis
4 phases
1. Incubation:
• Infection of mucosa→ lympadenopathy →
viremeia → RES → secondary viremia → reach
body surface to form exanthema
2. Prodrome:
• Mild fever, conjunctivitis, coryza, cough and
photophobia.
3. Enanthem:
• Koplick spots 1-4 days before exanthem;
• Inner cheek between premolars
• Also rarely on conjunctiva and vaginal mucosa
 4. Exanthem:
• Symptoms abate as rash appears
• Begins at 5-6 days after fever
• First seen around hairline and behind ears
• Maculopapular
• Spreads downwards to trunk and limbs
• Finally confluence and fade over 7 days
• Leaves brawny desquamation of skin
Enanthem: Koplick spots
Exanthem
 Clinical types of Measles
Subclinical measles Lab

• In immune persons • Decreased WBCs

• Mild or absent rashes • Decreased Lymphocytes

• ESR normal
• No shedding of virus • CRP not elevated
 Diagnosis:

• Koplick spot with typical rash

• Specific Ig. M increased

• Increasing titre of paired Ig. G serology

• Viral detection via culture or reverse

transcription–PCR
 Differential diagnosis
• includes rubella, scarlet fever, drug rashes

serum sickness, roseola infantum, infectious

mononucleosis, erythema infectiosum and

echovirus and coxsackievirus infections and

Kawasaki syndrome.
 DD
• Rubella: • Roseola infantum:
– fever is absent – Initial temperature is
– post auricular and sub usually high,
occipital lymph nodes – Koplik's spots and
are enlarged malaise are absent,
• Drug rashes: • Kawasaki syndrome:
– prodrome is absent, – increased polymorphs;
– no cephalocaudal – thrombocytosis;
progression or cough, increased acute phase
– history of recent drug reactants.
exposure.
 Treatment of Measles:
• No antiviral drugs
• Hydration, antipyretics, O2
• Ventilator support
• Vit A 1-2 L units
• IV ribaverin tried in immune deficiency.
• Prognosis: death 1 in 1000; 15 % in immune
deficiency.
• Prevention:
– Measles 9 month

– MMR in 15 months (?autism)

• Post exposure:
– Measles vaccine within 72 hrs

– IM/IV IgG within 6 days

•
PERTUSIS

Dr.p.natarajan
• Etiology:
– Bordetella pertusis: epidemic and sporadic causes

– Bordetella parapertusis: sporadic cases

– B.bronchiseptica: animal pathogen

• Epidemiology:
– World over 60 million cases and 500,000 deaths

– Vaccine caused >99% reduction in incidence

– 1-6 yr more susceptible

– More cases in older children

 Pathogenesis
• Gram negative coccobacilli

• Droplet infection

• Colonize only ciliated epithelium

• Local epithelial damage

• Pertusis toxin – mechanism unclear; inhibits

immune functions of host
 Clinical manifestations
• Incubation 3-12 days
• Catarrhal:
– 1-2 weeks; fever; rhinorrhea; lacrimation and conjunctival
suffusion
• Paroxysmal:
– 2-6 weeks
– Initial dry intermittent cough
– Machine – gun burst of uninterrupted cough
– Loud whoop
– Vomiting
– Clutches a comforting adult
• convalescent stage :
– 2 weeks
– Symptoms regress
Infants
and adults:
– No stages
– No typical cough or
whoop
– After a trigger may
develop signs of choking,
cyanosis and apnea.
– Paroxysm may continue
intermittently for a longer
period
– SIDS
Immunized children
– No distinct stages
– Whoop not
apparent
– Uninterrupted
cough
– Post tussive emesis
– Lasts for 3 weeks
 Physical findings

• Uninformative

• Secondary infection may show signs of pneumonia

• Conjunctival hemorrhage and petechiae on the

face

• Swollen eye lids

 Diagnosis
• Cough with whoop
• Absence of fever and lung signs
• Lymphocytosis
• Normal CXR
• Pharyngeal swap culture
• Bordet Gengou medium
• Colonies like mercury droplets
• PCR from throat swaps
• Serum for agglutinins
 Treatment
• Azithromycin 10 mg/kg od for 5 days

• Erythromycin for > 1 m infants (causes pyloric stenosis In

NB )

• Air way maintenance

• Quiet environment

• Mist inhalation

• Small frequent feeding

• Isolation: up to 5 days of treatment

 Complications

• Apnea
• Secondary infections
• Otitis media
• CNS hemorrhage
• Hernia
• Laceration of lingual frenulum
• SIDS
• Pertusis encephalopathy
 Prevention

• DPT (DTwP)

• Acellular pertusis vaccine (DTaP)

• Tdap for adolescents

 DIPHTHERIA

Dr.p.natarajan
 Definition

• Acute toxic infection caused by

corynebacterium diphtheriae
• Diphtheria in Greek means a piece of leather
• I st infection in history conquered by the
principles of bacteriology, immunology and
public health.
 Etiology
• corynebacterium diphtheriae are aerobic, nonencapsulated,

non-spore forming, non motile, pleomorphic, gram positive

bacilli

• Mitis, intermedius and gravis, belfanti are serotypes.

• Produce exotoxin after encoded by a bacteriophage

• C.ulcreans less commonly produce similar disease.

 Pathogenesis
• Transmission by droplets sometimes by contact
with skin lesion

• Asymptomatic carriers also spread the disease

• Children under 15 are susceptible

• Remain in superficial layers of respiratory mucosa

and multiply

• Induce cell necrosis by toxin

 Psuedomembrane
1. Cell necrosis, fibrin, leukocytes, epithelial cells , RBCs and
bacilli together form a dense membrane
2. Adherent to underlying tissues
3. Bleeds on peeling
4. Usually seen on tonsil and posterior fornix.
5. Nasal , laryngeal , conjunctival and cutaneous lesions possible
6. Cervical glands enlarge to form bull neck

7. Exotoxin affects heart, kidneys and CNS

Diphtheritic membrane and bull neck
 Clinical features
1. Incubation 2-5 days
2. Nasal:
1. Membrane in nares and upper lip
3. Faucial:
1. Membrane on tonsils, fornix, palate, pharynx and uvula
2. Cervical nodes enlarge
4. Laryngeal:
1. Membrane on larynx and can spread to trachea and
bronchi
– Hoarseness, stridor and croup
 Other sites
1. Cutaneous:
1. Non healing ulcers with grey brown membrane
2. Spreads to others
3. Provides immunity to host
2. Eye:
1. Ulcerative conjunctivitis
3. Vulvo vaginitis
4. Otitis externa
 Diagnosis

1. Culture from lesions

2. Smear to identify organisms

3. Toxigenicity to be determined ( Elek test)

4. PCR for toxin gene

 Complications
• Cardiomyopathy(10-24%)
1. 2nd week
2. Tachycardia
3. Prolonged P-R interwal
4. ST-T changes
5. Heart blocks
6. CCF
 Neuropathy

1. After 2-3 weeks 4. ciliary paralysis

2. Palatal palsy 4. Blurred vision
3. Occulomotor 5. Loss of accommodation
1. Strabismus 5. Peripheral neuritis
1. muscle weakness
2. Diaphragmatic paralysis
 DD

• Infectious mononucleosus

• Vincents angina

• Streptococcal pharyngitis

• herpes
 Treatment

• Antidiphtheritic serum after sensitivity tests

– Nasal: 10 to 20000 U IM

– Faucial: 15 to 25000 U IM/IV

– Laryngeal 20 to 40000 IM/IV

– Severe forms: 40 to 100 000 U half IM ; half IV

MUMPS
Etiology:
• Single stranded RNA; Family Para myxoviridae;
Genus Rubula virus
• Human beings are the only host
Epidemiology:
• Age: 5-9 yrs; epidemic at 4 yrs ; significant
reduction after vaccination
• Infectivity: 7 days before and 7 after parotid
swelling appears
 Pathology

• Can involve Salivary glands; CNS; Testes;

Thyroid; Ovaries; Heart; Kidneys; Liver; Joints.

• Infection → epithelium →lymphnode

→viremia →target tissues →necrosis with
lymphocytic infiltration → focal ischemia →
healing
 Clinical features
• Incubation 12-25 days
• Asymptomatic
• Non specific symptoms
• Typical illness:
– Prodrome: 1- 2 days of fever; headache and
vomiting;
– Unilateral or bilateral (70%) swelling of parotids;
tenderness; ear pain
Parotid swelling:
• Angle of lower jaw obscured

• Ear lobe lifted up and out

• Stensen duct opening red and swollen

• Sub mandibular glands can be involved

• Lymphatic obstruction leads to edema over sternum

Fever resolves in 3 days swelling in 7 days

Mumps Parotitis
Architis
 Diagnosis
• Increase in serum amylase
• Leucopenia
• Relative lymphocytosis
• Viral isolation
• PCR
• Paired serology: rise in titre of acute and convalescent
sera of IgG by
– Compliment fixation
– Hemagglutination
– Enzyme immuno assay and ELIZA
• Ig M by EIA demonstrates recent infection
 D.D
• Parotid swelling occurs in influenza; CMV; E.B virus; HIV; staph
infection(poly increased)
• Sialidinitis due to calculus
• Sjogren syndrome: autoimmune disorder in which immune cells
attack and destroy the exocrine glands that produce tears and
saliva. The hallmark symptoms of the disorder are dry mouth and
dry eyes (part of what are known as sicca symptoms).
• SLE: a chronic autoimmune connective tissue disease that can
affect any part of the body.SLE is one of several diseases known
as "the great imitators" because it often mimics or is mistaken for
other illnesses.
• Parotid tumour
 Complications
1. Meningitis; Encephalitis
2. Gonadal atrophy; 30% gonadal involvement; sterility if
bilateral; oopheritis can mimic appendicitis
3. Nerve deafness
4. Thrombocytopenia
5. Transverse myelitis
6. Pregnancy: fetal loss
7. Pancreatitis → diabetes
8. Myocarditis
9. Thyroiditis → myxaedema
10. Rare: optic neuritis; nephritis
Treatment:
– Non specific; pain killers and rest
Prognosis:
– good rarely death due to encephalitis
Prevention:
– MMR at 15 m and 5 yrs; contra indicated in egg
and neomycin allergy , pregnancy and HIV
RUBELLA
 Rubella
• Latin term meaning "little red."
• Rubella (German measles or 3-day measles) is a mild, often
exanthematous disease of infants and children
• Nearly one half of individuals infected with this virus are
asymptomatic. Clinical manifestations and severity of illness
vary with age
• More severe and associated with more complications in adults
with arthralgia, arthritis, and thrombocytopenic purpura.
• Rare cases of rubella encephalitis have also been described in
children.
• Its major clinical significance is transplacental infection
causing congenital defects, abortions, and stillbirths
 ETIOLOGY
• Family Togaviridae and is the only species of the
genus Rubivirus.
• Single-stranded RNA virus with a lipid envelope
• The virus is sensitive to heat, ultraviolet light, and
extremes of pH but is relatively stable at cold
temperatures.
• Humans are the only known host.
 EPIDEMIOLOGY
• Most common in preschool-aged and school-
aged children.
• Following introduction of the vaccine, the
incidence fell by >99%, with a relatively higher
percentage of infections reported among
persons >19 yr of age.
• Droplet infection

• respiratory epithelium → regional lymphatics→

primary viremia→ reticuloendothelial system→
secondary viremia→nasopharyngeal shedding of
virus → humoral and cellular immune response
 Clinical
• The incubation period 18 days
• prodromal symptoms, 1 to 5 days
• exanthem, consist of fever, eye pain, sore throat, arthralgia, and
gastrointestinal complaints.
• The characteristic clinical findings are:
1. Rash begins on the face, spreads in a cephalocaudal direction to
involve the entire body over the next 24 hours, and fades during
the ensuing 2 or 3 days, also in a cephalocaudal direction
2. Lymphadenopathy can be noted for up to 1 week before onset of
the exanthem. Usually, the posterior auricular and suboccipital
lymph nodes are involved, but generalized involvement can occur.