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MEASLES (RUBEOLA)
Abd El-Salam Dawood MD
Pediatric Cardiologist
FIBMS-Ped FIBMS-PedCard
Essentials of diagnosis & typical features:
Exposure to measles 9–14 days previously.
Prodrome of fever, cough, conjunctivitis,
and coryza.
Koplik spots (few to many small white
papules on a diffusely red base on the buccal
mucosa) 1–2 days prior to and after onset of
rash.
Maculopapular rash spreading down from
the face and hairline to the trunk over 3 days
and later becoming confluent.
Leukopenia.
General Considerations:
This childhood exanthem is "rarely" seen in the
developed countries because of vaccination.
The attack rate in susceptible individuals is extremely
high; spread is respiratory.
Morbidity and mortality rates in the developing world
are substantial because of underlying malnutrition
and secondary infections.
Because humans are the sole reservoir of measles,
there is the potential to eliminate this disease
worldwide.
Clinical Findings:
A history of contact with a suspected case may be
absent because airborne spread is efficient and
patients are contagious during the prodrome.
Contact with an imported case may not be
recognized.
In temperate climates, epidemic measles is a winter-
spring disease. Many suspected cases are
misdiagnoses of other viral infections.
Symptoms and signs:
High fever and lethargy are prominent.
Sneezing, eyelid edema, tearing, copious coryza,
photophobia, and harsh cough ensue and worsen.
Koplik spots are white macular lesions on the buccal
mucosa, typically opposite the lower molars. These
are almost pathognomonic for measles, although
they may be absent.
A discrete maculopapular rash begins when the
respiratory symptoms are maximal and spreads
quickly over the face and trunk, coalescing to a bright
red. As it involves the extremities, it fades from the
face and is completely gone within 6 days; fine
desquamation may occur.
Fever peaks when the rash appears and usually falls
2–3 days thereafter.
Laboratory findings:
Lymphopenia is characteristic. Total leukocyte counts
may fall to 1500/µL.
An experienced cytologist may see multinucleated
giant cells in oral mucosal scrapings and in nasal
secretions, but the diagnosis is usually made by
detection of measles IgM antibody in serum drawn at
least 3 days after the onset of rash or later by
detection of a significant rise in antibody. Direct
detection of measles antigen by fluorescent antibody
staining of nasopharyngeal cells is a useful rapid
method.
Imaging:
Chest x-rays often show hyperinflation, perihilar
infiltrates, or parenchymal patchy, fluffy densities.
Secondary consolidation or effusion may be visible.
Complications & Sequelae:
A. Respiratory complications
These occur in up to 15% of patients. Bacterial
superinfections of lung, middle ear, sinus, and
cervical nodes are most common. Fever that persists
after the third or fourth day of rash suggests such a
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complication, as does leukocytosis. Bronchospasm,
severe croup, and progressive viral pneumonia or
bronchiolitis
(in
infants)
also
occur.
Immunosuppressed patients are at much greater risk
for fatal pneumonia than are immunocompetent
patients.
B. Cerebral complications
Encephalitis occurs in 1 in 2000 cases. Onset is
usually within a week after appearance of rash.
Symptoms include combativeness, ataxia, vomiting,
seizures, and coma. Lymphocytic pleocytosis and a
mildly elevated protein concentration are usual CSF
findings, but the fluid may be normal. Forty percent
of patients so affected die or have severe neurologic
sequelae.
"Subacute sclerosing panencephalitis" is a slow
measles virus infection of the brain that becomes
symptomatic years later in about 1 in 100,000
previously infected children. This progressive
cerebral deterioration is associated with myoclonic
jerks and a typical EEG pattern. It is fatal in 6–12
months. It rarely occurs following administration of
vaccine, with an estimated incidence of less than 1
per 1,000,000 vaccinated individuals. High titers of
measles antibody are present in serum and CSF.
C. Other complications:
These include hemorrhagic measles (severe
disease with multiorgan bleeding, fever, cerebral
symptoms), thrombocytopenia, appendicitis,
keratitis, myocarditis, and premature delivery
or stillbirth. Mild liver function test elevation has
been detected in up to 50% of cases in young adults;
frank jaundice may also occur. Measles causes
transient immunosuppression; thus, reactivation
or progression of tuberculosis (including transient
cutaneous anergy) occurs in untreated children.
Treatment, Prognosis, & Prevention:
Recovery generally occurs 7–10 days after onset of
symptoms.
Therapy is supportive: eye care, cough relief (avoid
opioid suppressants in infants), and fever reduction
(acetaminophen, lukewarm baths; avoid salicylates).
Secondary bacterial infections should be treated
promptly; antimicrobial prophylaxis is not indicated.
Ribavirin is active in vitro and may be useful in
infected immunocompromised children.
In
malnourished
children,
vitamin
A
supplementation should be given to attenuate the
illness.
The current two-dose active vaccination strategy is
successful. Vaccine should not be withheld for
concurrent mild acute illness, tuberculosis or positive
tuberculin skin test, breast-feeding, or exposure to
an immunodeficient contact. The vaccine is
recommended for HIV-infected children without
severe HIV complications and adequate CD4 cells (³
15%).
Vaccination prevents the disease in susceptible
exposed individuals if given within 72 hours.
Immune globulin (0.25 mL/kg intramuscularly; 0.5
mL/kg if immunocompromised) will prevent or
modify measles if given within 6 days.
Suspected cases should be diagnosed promptly and
reported to the local health department