Measles

Aka: Measles, Rubeola, Morbilli, First Viral Exanthem of childhood, Red Measles, Koplik Spots

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II. Epidemiology

  1. Sporadic outbreaks in teenagers and young adults
  2. Incidence: World
    1. Worldwide Measles deaths 150,000 per year, esp. in age <5 years old (600,000/year before year 2000)
  3. Incidence: U.S
    1. U.S. Cases in 1941: 894,000 cases
    2. U.S Cases before 1967
      1. Infected: 500,000 cases/year
      2. Hospitalized: 50,000 cases/year
      3. Deaths: 500 deaths/year
    3. U.S. Cases in 2000: 86 cases
    4. U.S. Cases in 2014: 667 cases (especially in California, Ohio, New York City)
      1. Reintroduced from endemic regions via international travel
      2. U.S. transmission is increased via unimmunized patients (failed Herd Immunity)
    5. U.S. Cases in 2017: 100 cases as of May 20, 2017
      1. Measles outbreak in Minnesota related to unimmunized Somali community
      2. Community had been convinced not to immunize based on false MMR Autism links
      3. http://www.npr.org/sections/health-shots/2017/05/03/526723028/autism-fears-fueling-minnesotas-measles-outbreak
    6. U.S. Cases in 2019
      1. So far, in only the first 3 months of 2019, there have been 387 Measles cases
  4. References
    1. CDC Measles Statistics
      1. https://www.cdc.gov/measles/cases-outbreaks.html

III. Pathophysiology

  1. Genus: Morbillivirus
  2. Incubation: 8-12 days (from exposure to rash onset)
    1. Range: 7-18 days (rarely up to 21 days)
  3. Transmission
    1. Infectivity starts 4 days before symptoms and extends to 4 days after rash onset
    2. Droplets of nasopharyngeal secretions
    3. Highly contagious
      1. Affects 90% of susceptible household contacts

IV. Symptoms

  1. Prodrome (precedes the rash by 2-3 days)
    1. Classic "3 C's"
      1. Severe Cough (dry, hacking)
      2. Coryza
      3. Conjunctivitis
    2. High Fever (up to 105 F or 40.5 C)
    3. Malaise
    4. Irritability
    5. Photophobia
  2. Koplik Spots in Mouth (3-4 days after start of prodrome)
  3. Erythematous maculupapular rash (3-5 days after start of prodrome)
    1. Rash spreads from forehead, behind the ears and neck
    2. Then spreads to trunk and then to extremities (1-2 days later)
    3. Patients are contagious 4 days prior to rash onset
    4. Other symptoms begin to decrease after rash onset (esp. after foot involvement)
    5. Rash resolves over the following 5-10 days, followed by Desquamation

V. Signs

  1. Koplik Spots (pathognomonic, 60-70% of cases)
    1. Grayish-white sand-like clustered dots
    2. Slight, reddish areolae that may be hemorrhagic with a bluish-white center
    3. Often opposite upper first and second molars
    4. My spread to involve any of Buccal mucosa, lips, Gingiva, Hard Palate
    5. May also affect the Conjunctiva, vaginal mucosa
  2. Fever (Onset with rash)
  3. Blotchy red-brown, maculopapular, Morbilliform rash
    1. Discrete red-brown Macules blanch with pressure
    2. Begins on forehead
    3. Spreads to face and neck, behind ears
    4. Spreads to trunk and extremities
    5. Palms and soles are affected in up to 50% of patients
    6. Rash resolves over the subsequent 5 to 10 days, then desquamates in the next week
  4. Cervical Lymphadenopathy

VI. Labs: Measles Diagnosis

  1. Approach
    1. Measles clinical case definition (symptom criteria)
      1. Fever with Temperature >= 101°F (38.3°C) AND
      2. Cough, Coryza, or Conjunctivitis AND
      3. Generalized, maculopapular rash that lasts for at least 3 days
    2. Testing Indications
      1. Rash AND Fever AND 1 of 3 upper respiratory symptoms (Cough or Coryza or Conjunctivitis) OR
      2. Rash AND Fever alone if risk factors (known exposure or international travel in last 30 days)
    3. Resources
      1. When to Suspect and Test for Measles (Minnesota Department of Health)
        1. http://www.health.state.mn.us/divs/idepc/diseases/measles/hcp/whensuspect.pdf
  2. Measles PCR (blood, throat, nasal secretions or urine) - First Line Testing
    1. Testing at 0-5 days after rash onset
      1. Measles throat swab or nasal swab PCR
    2. Testing at 6-9 days after rash onset
      1. Measles throat swab or nasal swab PCR and
      2. Measles urine PCR
  3. Measles Serology (IgG and IgM) - May be performed in addition to PCR
    1. Measles IgM is positive within first few days of rash onset (elevated for the first month)
  4. Older test modalities (where PCR not available)
    1. Viral culture of throat, nasal secretions or urine
  5. References
    1. Minnesota Department of Health Measles Lab Testing
      1. http://www.health.state.mn.us/divs/idepc/diseases/measles/hcp/index.html#lab

VII. Labs: Other Testing

  1. Complete Blood Count
    1. Pancytopenia with Thrombocytopenia may occur in severe cases
    2. Leukopenia during prodrome
      1. Lymphocytes <2000 associated with worse prognosis
  2. Liver Function Tests
    1. Transaminases increase in Measles hepatitis
  3. Respiratory secretions
    1. Respiratory secretions with multinucleated giant cells
    2. Immunofluorescent staining of respiratory cells
  4. Acute phase reactants
    1. C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR)
      1. Mildy elevated in Measles
      2. Higher when Bacterial superinfection is present

VIII. Differential Diagnosis

  1. Dengue Fever (tropical travel)
  2. Roseola Infantum (Human Herpes Virus 6)
  3. Kawasaki Disease
  4. Erythema Infectiosum (Parvovirus B19, Fifth Disease)
  5. Scarlet Fever (Streptococcal Pharyngitis)
  6. Coxsackievirus
  7. Infectious Mononucleosis
  8. Echovirus
  9. Drug Reactions
  10. Rubella
  11. Rocky Mountain Spotted Fever
  12. Toxic Shock Syndrome

IX. Course

  1. Severity related to extent and confluence of the rash
  2. When rash reaches feet, clinical improvement has begun

X. Management

  1. Supportive care
  2. Suspected cases
    1. Contact local public health department (initiate testing, contact tracing)
    2. Exposure precautions in hospital
    3. Discharged patients should self quarantine until definitive diagnosis
    4. Do not have patients with Fever and Rash wait in a common waiting room, exposing others
  3. Prevent spread
    1. Have patients wear a mask, and place in isolation during the evaluation
    2. Patients should quarantine themselves at home
    3. Patients and their household contacts should use Airborne Isolation protection for at least 4 days after rash onset
    4. Offer Postexposure Prophylaxis to nonimmune contacts (see prevention below)
  4. Immunocompromised patients
    1. Consider Ribavirin
    2. Immunocompromised patients should be isolated for the entire duration of Measles infection
      1. Prolonged viral shedding
  5. Children
    1. Vitamin A
      1. Decreases morbidity and mortality and is recommended by WHO for all children with Measles
  6. Exposed healthcare workers
    1. Non-immune healthcare workers should be offered Postexposure Prophylaxis (preferably MMR Vaccine, see below)
    2. Non-immune healthcare workers should be off work from day 5 after first exposure to day 21 after last exposure

XI. Complications

  1. Background
    1. Measles results in a relative Immunosuppression, with higher risk of superinfections
    2. Hospitalization rates in Measles patients approaches 20% (due to complications)
  2. Early Common Effects
    1. Otitis Media
    2. Diarrhea and Dehydration (may be severe)
  3. Early Severe Effects
    1. Pneumonitis
    2. Pneumonia (3-5% of young adults)
      1. May result directly from measles Pneumonia or from Bacterial superinfection
      2. Includes Interstitial Giant Cell
    3. Hepatitis
    4. Glomerulonephritis
    5. Myocarditis
    6. Encephalitis (1 per 1000 Measles cases)
      1. Onset 4-7 days after rash
      2. Presents with Seizures, lethargy, Altered Mental Status
      3. Exclude other causes of Meningitis and Encephalitis including Bacterial Meningitis
      4. Mortality: 10%
      5. Immune-mediated response
  4. Late Effects
    1. Subacute sclerosing panencephalitis (SSPE)
      1. Incidence: 8.5 cases per 1 million Measles cases
      2. Onset 7 to 10 years after Measles infection
      3. Presents with progressive decline in intellectual and behavioral function
        1. Associated with Dementia and neuromuscular disorders (e.g. Ataxia, Seizures)
        2. Poor prognosis and results in death in most cases
  5. Mortality
    1. Developed countries: 1-2 deaths per 1000 Measles cases
    2. Developing countries: 1-2 deaths per 100 Measles cases
    3. Worldwide (2013): 145,700 deaths (400 per day or 16 per hour)
    4. Highest mortality in infants and young children and Immunocompromised patients
    5. Mortality is also high in unimmunized pregnant women

XII. Prevention: Active Immunization

  1. MMR Vaccine
    1. See MMR Vaccine
    2. MMR Vaccine is part of primary Immunization series with 2 dose Vaccination (12 to 15 months, 4 to 6 years)
    3. Very effective Vaccine (97% lifelong protection after 2 doses)
    4. MMR Vaccine is safe (many studies have shown no association with Autism)
    5. Avoid delaying MMR Vaccination (perform at scheduled time: 12-15 months and 4-6 years)
    6. Measles is the most contagious of the Vaccine preventable diseases (affects 90% of those exposed)
    7. MMR Vaccine is contraindicated in Immunocompromised patients and pregnancy
    8. Adults born in U.S. before 1957 may be assumed immune
    9. Those who are immunized and still acquire Measles tend to have mild course and are less contagious

XIII. Prevention: Post-exposure Prophylaxis

  1. MMR Vaccine
    1. MMR Vaccine may be given within 72 hours of exposure
  2. Immunoglobulin post exposure (passive Immunization)
    1. Dose
      1. Gamma globulin: 0.25 ml/kg (MAX 15 ml)
    2. Indications (within 6 days of exposure)
      1. Infants <12 months old
        1. May instead use Measles Vaccine for ages 6-12 months for exposure within 72 hours
      2. Pregnant women without measles Immunity
      3. Close, prolonged patient contact without measles Immunity
      4. Tuberculosis
      5. Immunocompromised patients

XIV. Resources

  1. CDC Measles
    1. http://www.cdc.gov/measles/

XV. References

  1. Baringa and Skolnik in Hirsch and Kaplan, Measles, UpToDate, accessed 1/28/2015
  2. Chen in Steele, Measles, Medscape EMedicine, accessed 1/28/2015
  3. Harrison and Ruttan (2019) Crit Dec Emerg Med 33(7): 3-12
  4. Harrison and Ruttan (2023) Crit Dec Emerg Med 38(2): 23-31
  5. Wallace and Spangler in Herbert (2015) EM:Rap 15(2): 2-3

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