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Measles (Rubeola)

- GI complications: diarrhea (may lead to dehydration) - Neurologic complications - Febrile seizures - Acute disseminated encephalomyelitis with seizures and neurologic abnormalities (occurs in 1/1,000 cases): presents within 2 weeks of rash, probably an autoimmune response - Inclusion body encephalitis is rare but fatal in those with defective cellular immunity. - Subacute sclerosing panencephalitis - Rare degenerative CNS disease resulting from persistent measles infection following natural disease; usually fatal - Presents 5 to 15 years after infection - Most often in persons infected before age 2 years

para>Report suspected measles cases to public health authorities. ‚

TREATMENT

GENERAL MEASURES

  • Place all patients with measles in respiratory isolation until 4 days after onset of rash; immunocompromised patients should be isolated for duration of illness.
  • Supportive therapy (i.e., antipyretics, antitussives, humidification, increased oral fluid consumption)

MEDICATION

  • No approved antiviral therapy is available. Immunosuppressed children with severe measles have been treated with IV or aerosolized ribavirin. No controlled trial data exist, and this use is not FDA approved.
  • Vitamin A: WHO recommends daily dosages for two consecutive days:Children <6 months of age 50,000 IUChildren 6 to 12 months of age 100,000 IUChildren >12 months of age 200,000 IU
  • AntibioticsReserved for patients with clinical signs of bacterial superinfection (pneumonia, purulent otitis, pharyngitis/tonsillitis) (6)[B]A small randomized, double-blinded trial resulted in an 80% (number needed to treat [NNT] = 7) decrease in measles-associated pneumonia with prophylactic antibiotics; consider antibiotic use prophylactically in patients with a high risk of complications (7)[B].
  • Outbreak controlA single case of measles constitutes an outbreak.Immunize contacts (individuals exposed or at risk of having been exposed) within 72 hours.Monovalent vaccine may be given to infants 6 months to 1 year of age, but two further doses of vaccine after 12 months must be given for adequate immunization.Monovalent or combination vaccine may be given to all measles-exposed susceptible individuals age >1 year if not contraindicated.Individuals not immunized within 72 hours of exposure should be excluded from school, child care, and health care settings (social quarantine) until 2 weeks after onset of rash in last case of measles.Immunoglobulin therapy (passive immunity) may be necessary for the following high-risk individuals exposed to measles for whom vaccine is inappropriate:Children age <1 year (infants 6 to 12 months of age may receive MMR vaccine in place of IG if given within 72 hours of exposure)Pregnant womenIndividuals with severe immunosuppressionIM immunoglobulin should be given within 6 days of measles exposure; CDC recommends 0.25 mL/kg to maximum of 15 mL for infants and pregnant women; immunocompromised individuals receive 0.5 mL/kg to a maximum of 15 mL.

INPATIENT CONSIDERATIONS

Outpatient care is appropriate, except where complications develop (e.g., encephalitis, pneumonia). ‚

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Signs of complications needing close follow-up include: ‚

  • Difficulty breathing or noisy breathing
  • Changes in vision
  • Changes in behavior, confusion
  • Chest or abdominal pain

PATIENT EDUCATION

  • Adhere to recommended immunization schedules.
  • Avoid exposure, particularly to unimmunized children and adults, pregnant women, and immunocompromised persons, until 4 days after rash onset.
  • Avoid contact with potential sources of secondary bacterial pathogens until respiratory symptoms resolve.
  • Centers for Disease Control and Prevention. Measles. www.cdc.gov/measles/about/index.html

PROGNOSIS

  • Typically self-limited; prognosis good
  • High fatality rates may be seen among malnourished or immunocompromised children, particularly in developing countries.

COMPLICATIONS

  • Otitis media (5 " “15%)
  • The immune response to measles infection paradoxically depresses response to non " “measles-virus antigens, which renders individuals more susceptible to pneumonia and diarrhea.
  • Respiratory complications:Bronchopneumonia (5 " “10%)Accounts for most measles-related deathsMay be viral or bacterialInterstitial pneumonitis (immunocompromised patients)Laryngotracheobronchitis ( "measles croup " ť): occurs in younger age group (<2 years)
  • GI complications: diarrhea (may lead to dehydration)
  • Neurologic complicationsFebrile seizuresAcute disseminated encephalomyelitis with seizures and neurologic abnormalities (occurs in 1/1,000 cases): presents within 2 weeks of rash, probably an autoimmune responseInclusion body encephalitis is rare but fatal in those with defective cellular immunity.Subacute sclerosing panencephalitisRare degenerative CNS disease resulting from persistent measles infection following natural disease; usually fatalPresents 5 to 15 years after infectionMost often in persons infected before age 2 years
  • Ocular complicationsKeratitisCan lead to permanent scarring, blindnessVitamin A deficiency predisposes to more severe keratitis and its complications.
  • Other secondary bacterial infections
  • Death: results from complications, mainly pneumonia, rather than the virus itself. CDC statistics show that for every 1,000 children who get measles, 1 or 2 will die.

REFERENCES

11 Lessler ‚ J, Reich ‚ NG, Brookmeyer ‚ R, et al. Incubation periods of acute respiratory viral infections: a systematic review. Lancet Infect Dis. 2009;9(5):291 " “300.22 Orenstein ‚ W, Seib ‚ K. Mounting a good offense against measles. N Engl J Med. 2014;371(18):1661 " “1663.33 Althouse ‚ BM, Bergstrom ‚ TC, Bergstrom ‚ CT. Evolution in health and medicine Sackler colloquium: a public choice framework for controlling transmissible and evolving diseases. Proc Natl Acad Sci U S A. 2010;107(Suppl 1):1696 " “1701.44 Rowhani-Rahbar ‚ A, Fireman ‚ B, Lewis ‚ E, et al. Effect of age on the risk of fever and seizures following immunization with measles-containing vaccines in children. JAMA Pediatr. 2013;167(12):1111 " “1117.55 Demicheli ‚ V, Jefferson ‚ T, Rivetti ‚ A, et al. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2005;(4):CD004407.66 Kabra ‚ SK, Lodha ‚ R. Antibiotics for preventing complications in children with measles. Cochrane Database Syst Rev. 2013;(8):CD001477.77 Garly ‚ ML, Bale ‚ C, Martins ‚ CL, et al. Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ. 2006;333(7581):1245.

ADDITIONAL READING

  • Mulholland ‚ EK, Griffiths ‚ UK, Biellik ‚ R. Measles in the 21st century. N Engl J Med. 2012;366(19):1755 " “1757.
  • Papania ‚ MJ, Wallace ‚ GS, Rota ‚ PA, et al. Elimination of endemic measles, rubella, and congenital rubella syndrome from the western hemisphere: the US experience. JAMA Pediatr. 2014;168(2):148 " “155.

CODES

ICD10

  • B05.9 Measles without complication
  • B05.2 Measles complicated by pneumonia
  • B05.89 Other measles complications
  • B05.81 Measles keratitis and keratoconjunctivitis
  • B05.3 Measles complicated by otitis media
  • B05.4 Measles with intestinal complications
  • B05.1 Measles complicated by meningitis
  • B05.0 Measles complicated by encephalitis

ICD9

  • 055.9 Measles without mention of complication
  • 055.1 Postmeasles pneumonia
  • 055.79 Measles with other specified complications
  • 055.71 Measles keratoconjunctivitis
  • 055.8 Measles with unspecified complication
  • 055.0 Postmeasles encephalitis
  • 055.2 Postmeasles otitis media

SNOMED

  • 14189004 Measles (disorder)
  • 195900001 measles pneumonia (disorder)
  • 38921001 Measles with complication
  • 60013002 Measles keratoconjunctivitis (disorder)
  • 406592004 Measles of the central nervous system (disorder)
  • 111873003 Measles without complication (disorder)

CLINICAL PEARLS

  • There is no substantiated link between MMR vaccine and autism.
  • Measles is a highly communicable viral disease whose natural transmission has been halted in the United States by mass immunization.
  • A single case of measles constitutes an outbreak.
  • Suspected measles cases must be reported to state or local health departments to contain outbreak.
  • Immunization requires two doses: one at 12 to 15 months of age and one at school age (4 to 6 years of age).
  • Presentation includes a prodrome of fever, cough, coryza, and conjunctivitis, followed by a descending maculopapular rash beginning on the face and progressing to the chest and lower body (centrifugal).
  • Consider measles in the differential diagnosis of a febrile rash illness (especially in unvaccinated individuals with recent international travel).
  • Measles-associated pneumonia is the most common cause of mortality.