MEASLES

JERVY B. PLIMACO-GARCIA
JUNIOR INTERN
 OBJECTIVES

THIS PRESENTATION AIMS TO:

• To recognize the clinical presentation of a pediatric
patient with measles;
• To differentiate measles from other infectious diseases that present
with fever and rash;
• To initiate appropriate management of measles
• To identify preventive measures against measles
 IDENTIFYING DATA

• S.P.U. 5/F
• January 14, 2014
• Roman Catholic
• Filipino
• Sto. Nino, Tanauan Leyte
• Admitted for the first time at RTRH on Feb 05, 2019 at 10 a.m..
Chief complaint:

fever & rashes

 History of present illness

4 days prior to admission

• fever (Tmax: 40 C)
• no other associated signs and symptoms
• Paracetamol 250mg/5ml computed at 15 mkd every 4
hours
• temporary relief
 History of present illness (cont.)

3 days prior to admission

• febrile
• Nonproductive cough and colds with watery nasal
discharge
• no other associated signs and symptoms
• Paracetamol 250mg/5ml, computed at 15 mkd every 4 hours
• No consult
 History of present illness (cont.)
1 day prior to admission
• Febrile, nonproductive cough, colds
• Generalized abdominal pain
• Headache
• rashes on the face
• Prompted consult
 REVIEW OF SYSTEMS
• GENERAL: (+) decreased appetite, (+) fever, (+)
body malaise, (+) decreased physical activity, (-)
weight loss,
• SKIN: rashes on the face, no itchiness, sores,
lesions, pallor,
• HEAD: headache, lightheadedness, dizziness
• EYES: (+) redness, no pain blurring of vision or
excessive tearing
 REVIEW OF SYSTEMS (cont.)

• NOSE AND SINUSES: no nasal stuffiness, (+) clear

watery nasal discharges, no itching, no epistaxis
• MOUTH AND THROAT: (-) sore throat, no
hoarseness, no bleeding gums
• NECK: no pain, no rigidity, no lumps
• RESPIRATORY: cough, no dyspnea, orthopnea,
hemoptysis
 REVIEW OF SYSTEMS (cont.)

• CARDIOVASCULAR: no chest pains, palpitations

• GIT: no nausea, no vomiting, no LBM
• GUT: no hematuria, dysuria, polyuria
• GENITALIA: no discharges, no itching
 REVIEW OF SYSTEMS (cont.)
• PERIPHERAL VASCULAR: no leg cramps
• MUSCULOSKELETAL: no joint pains, no
backaches, no weakness
• HEMATOLOGIC: no easy bruising
• ENDOCRINE: no excessive thirst/hunger, no
heat/cold intolerance
• PSYCHIATRIC: no nervousness, tension, memory
loss
 PAST MEDICAL HISTORY

× Measles and Chickenpox

× mumps

× asthmatic

× allergies to food and drugs

 PAST MEDICAL HISTORY (cont.)

× previous hospitalizations

Immunization history: fully immunized child

 FAMILY HISTORY
CALUPAS -UDTUHAN FAMILY
Feb 07, 2019
Tanauan Leyte
? ?

I
Evarnesto Pilar
xx
Sixto
x ?
Charito
76 71 71 52
I I I I I I I I I I I I I
II

Romeo Elsa
47 44

III
Eadrien Roxell Zhamei Ay-ar Romeo Shania
e27 23 16 13
17 5
LEGEND:
Hypertension -
DM -
 PSYCHOSOCIAL HISTORY

Lives with family in a semi concrete house electricity

and with a flushed type toilet.
Adequate ventilation
Good sanitation, garbage; collected once a week
Commercially available purified drinking water
 PHYSICAL EXAMINATION
GENERAL SURVEY
• Awake, conscious, cooperative, not in cardiorespiratory distress
• Febrile
VITAL SIGNS ACTUAL VALUE
Blood Pressure 90/60 mmHg

Temperature 38.9 °C (L axilla)

Heart Rate 104 bpm

Respiratory Rate 23 cpm

Weight 16 kg

Height 112 cm
 PHYSICAL EXAMINATION (cont.)

INTEGUMENT
• Fair complexion, warm, good skin turgor
• Nails pinkish, normal CRT
• No masses, no lumps, no rashes
• (+) maculopapular rash on the face, neck, trunk, upper and lower
extremities
HEAD
• Hair black, short, fine, average in texture
• No nits/lice infestation, no visible flakes
• No lumps, no tenderness, no scars, no engorged veins
 PHYSICAL EXAMINATION (cont.)

EYES
• Eyebrows symmetrically aligned, fine, black
• Eyelashes fine, black, oriented outwards
• Eyelids not edematous
• (+) conjunctival redness,
• Non-sunken eyeballs
EARS
• Symmetrical, firm pinnae
• No abnormal discharge and no active lesions
 PHYSICAL EXAMINATION (cont.)
NOSE
• (-) Septal deviation, (-) Epistaxis, (-) Nasal flaring
• (+) watery nasal discharge
MOUTH & THROAT
• Moist lips, moist oral mucosa
• (+) Koplik’s spots
• No bleeding/sores
NECK
• Supple, trachea at midline, neck veins not engorged
• No lymphadenopathies
 PHYSICAL EXAMINATION (cont.)

CHEST AND LUNGS

• Symmetrical chest expansion, no bulging
• No supraclavicular, intercostal, and subcostal retractions
• Resonant in all lung fields
• Clear breath sounds, no crackles and wheezes
HEART
• Adynamic precordium
• Apex beat palpable at 5th ICS LMCL, (-) thrills/heaves
• HR at 104 bpm, regular in rhythm
• (-) Murmurs
 PHYSICAL EXAMINATION (cont.)
ABDOMEN
• flat,
no visible peristalsis, no engorged veins, no hyper- nor
hypopigmentation,
• normoactive bowel sounds, no bruit, no venous hum, no
peritoneal friction rub
• soft, non-tender
BACK AND SPINE
• (-) Abnormal deviation, (-) retractions
• (-) Bulging, (-) muscle wasting
GENITAL & RECTUM/ANUS
 SALIENT FEATURES

IDENTIFYING DATA: 5 years old, female

HISTORY OF PRESENT ILLNESS:
• fever (Tmax: 40 C)
• Nonproductive cough, colds
• Generalized abdominal pain
• Headache
• (+) Maculopapular rashes on the face
 SALIENT FEATURES

ROS:
• decreased appetite, decreased activity, body malaise
P/E:
• Febrile (38.9C), maculopapular rashes on face, neck, trunk,
bilateral upper and lower extremities, conjunctival redness , (+)
Koplik’s spot, (-) cervical lymphadenopathy, clear breath sounds,
(-) tenderness abdomen, full equal pulses
 DIFFERENTIAL DIAGNOSIS

Fever and Rash

Blanching?
YES NO

Non petechial Petechial

Papule/ Maculopapular
Macule Vesicule/Pustule
MACULE PAPULAR, VESICULAR, MACULOPAPULAR PETECHIAL
PUSTULAR

Rubella (German
Juvenile Idiopathic Varicella measles, third Dengue fever
Arthritis disease)

Lyme disease Scarlet fever Roseola Infantum Chikungunya

Toxic shock Erythema

syndrome Infectiosum
Rule in Rule out
 IMPRESSION: MEASLES, eruptive stage

BASIS:
HISTORY OF PRESENT ILLNESS:
• Patient had onset of fever with Tmax of 40 C
• Nonproductive cough, colds
• Generalized abdominal pain
• Headache
• (+) Maculopapular rashes on the face
 IMPRESSION: MEASLES, eruptive stage

ROS:
• decreased appetite, decreased activity, body malaise
P/E:
• Febrile (38.9C), maculopapular rashes on face, neck, trunk,
bilateral upper and lower extremities, conjunctival redness ,
(+) Koplik’s spot, (-) cervical lymphadenopathy, clear breath
sounds, (-) tenderness abdomen, full equal pulses
DISCUSSION
Myalgia
• Measles, also known as rubeola,
is one of the most contagious
infectious diseases, with at
least a 90% secondary infection
rate in susceptible domestic
contacts. Despite being
considered primarily a childhood
illness, measles can affect
people of all ages.
 Etiology
• caused by a spherical RNA virus of the genus Morbillivirus and family Paramyxoviridae

• relatively large, with an RNA genome

• related to canine distemper and rinderpest viruses, but does not possess specific
neuraminidases
• it hemagglutinates while the others do not

• Measles virus is heat labile

• Humans are the natural host but monkeys can become infected.
Microscopic (histologic) description
• Epithelial giant cells with viral inclusions

• Nuclei may contain a single large Cowdry

type A inclusion

• Reticuloendothelial (Warthin-Finkeldey) giant

cells may be found in lymphoid tissue
 Infectivity and Transmission
• incubation period from exposure to onset of measles
symptoms ranges from 7 to 14 days (average, 10-12 days)

• contagious from 1-2 days before the onset of symptoms

• Healthy children are contagious during the period from 3-5

days before the appearance of the rash to 4 days after the
onset of rash. On the other hand, immunocompromised
individuals can be contagious during the duration of the
illness.

• This highly contagious virus is spread by coughing and

sneezing via close personal contact or direct contact with
secretions.
 Pathogenesis
Initial infection and viral replication occur
locally in tracheal and bronchial epithelial
cells

measles virus infects local lymphatic

tissues, perhaps carried by pulmonary
macrophages

cell-associated viremia
disseminates the virus to various
organs
 Prodromal phase

High fever lasting 4-7days

Malaise
Fever
Anorexia
3C’s
 Enanthem
characteristic enanthem generally
appears 2-4 days after the onset of the
prodrome/appearance of rashes and lasts
3-5 days
Koplik spots (bluish-gray specks or
“grains of sand” on a red base) appear on
the buccal mucosa opposite the second
molars
begins to slough as the rash appears

Although this is the pathognomonic

enanthem of measles, its absence does
not exclude the diagnosis
 Exanthem
Blanching, erythematous macules and
papules begin on the face at the hairline,
on the sides of the neck, and behind the
ears
Within 48 hours, they coalesce into patches
and plaques  spread cephalocaudally to
the trunk and extremities, including the
palms and soles, while beginning to regress
cephalocaudally, starting from the head and
neck
Lesion density is greatest above the
shoulders, where macular lesions may
coalesce.

entire course of uncomplicated

measles, from late prodrome to
resolution of fever and rash, is 7-10
days.
Morbilliform rash
 Complications
Pneumonia is the most frequent complication

likely to occur in persons < 5 years or > 20 years and

increased in persons with immune deficiency disorders,

malnutrition, vitamin A deficiency, and inadequate
vaccination. Immunocompromised children and adults are at
increased risk for severe infections and superinfections

Others: otitis media, interstitial pneumonitis,

bronchopneumonia, laryngotracheobronchitis (ie, croup), and
exacerbation of tuberculosis
Subacute sclerosing Panencephalitis, a degenerative CNS
disease that can result from a persistent measles infection.

-characterized by behavioral and intellectual deterioration and

seizures years after an acute infection (the mean incubation
period is 10.8 years).

Measles in the pregnant pneumonitis, hepatitis, subacute

sclerosing panencephalitis, premature labor, spontaneous
abortion, and preterm birth of the fetus. Perinatal transmission
rates are low.
 Diagnosis

• determined from the classic clinical picture, including

the classic triad of cough, coryza, and conjunctivitis; the
pathognomonic Koplik spots; and the characteristic
cephalocaudal progression of the morbilliform exanthem.
 Management
• Supportive care

• Antiviral therapy

• Vitamin A supplementation
 Post exposure prophylaxis

• Measles vaccine
• preventive if administered within 3 days of exposure

• Human Immunoglobulin
• prevents or modifies disease in susceptible contacts if
administered within 6 days of exposure
 AT THE ER (Feb 05, 2019—10AM)
• DIAGNOSTICS
• CBC, plt
• BT
• DRT
• Urinalysis
• CXR APL
• VENOCLYSIS: PLR 500cc at 80cc/hr (30cc/kg/hr)
• MEDICATIONS
• Paracetamol 160 mg IVTT now then q4hrs PRN for T> 39C
• Paracetamol 250mg/5ml, 5ml q4hrs prn for fever T> 37.8C
• Ceterizine 5mg/5ml 4ml ODHS
 CBC, plt (Feb 05, 2019)
HEMOGLOBIN: 123 SEGMENTERS: 0.63
HEMATOCRIT: 0.40 LYMPHOCYTES: 0.36

WBC: 2.9 MONOCYTES: 0.01

PLATELET: 382
 DRT (Feb 05, 2019)

•NS1 Ag: Negative

•IgM: Negative
•IgG: Negative
 BT (Feb 05, 2019)

•B +
 URINALYSIS (Feb 05, 2019)

• Light yellow, clear, 1.005, 6.0,

• pus 1-2, rbc 0-2,
• epithelial cells few, bacteria few, A.urates few, M.threads few
• protein negative, sugar
negative
 CHEST XRAY APL VIEW
(Feb 05, 2019)

• IMPRESSION:
• No significant chest findings
 Feb 05, 2019 (5PM)

• Ranitidine 16mg IVTT now then q8hrs

• Decrease present IVF rate to 48 cc/hr
• IVF to follow: PLR 500cc at 48 cc/hr (3 cc/kg/hr)
• Salbutamol Neb 1 neb now then q8hrs
• Cefuroxime 500mg IV q8hrs ANST
• Paracetamol 250mg/5ml 5ml now then q 4 hrs RTC
 Feb 06, 2019

• IVF to follow PLR 500cc @ 50cc/hr

• Cont. medications
 Feb 07, 2019 (12:35pm)

• IVF to follow D5 0.3 NaCl 500cc @40cc/hr

• For repeat CXR PAL tomorrow