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11 Measles


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11 Measles

  1. 1. MEASLES
  2. 2. <ul><li>Measles is… </li></ul><ul><li>an acute viral infection characterized by a maculopapular rash erupting successively over the neck, face, body, and extremitis and accompanied by a high fever. </li></ul>DEFINITION
  3. 3. ETIOLOGY <ul><li>Measles virus </li></ul><ul><li>An RNA virus of the genus Morbillivirus in the family of Paramyxoviridae </li></ul><ul><li>One serotype, human’s only host </li></ul><ul><li>Stable antigenicity </li></ul><ul><li>Rapidly inactivated by heat and light </li></ul><ul><li>Survival in low temperature. </li></ul>
  4. 4. EPIDEMIOLOGY <ul><li>Infection sources </li></ul><ul><ul><li>Patients of acute stage and viral carriers of atypical measles </li></ul></ul><ul><li>Transmission </li></ul><ul><ul><li>Highly contagious, approximately 90% of susceptible contacts acquire the disease. </li></ul></ul><ul><ul><li>Respiratory secretions : maximal dissemination of virus occurs by droplet spray during the prodromal period (catarrhal stage). </li></ul></ul><ul><ul><li>Contagious from 5 days before symptoms , 5 days after onset of rash </li></ul></ul><ul><ul><li>Seasons: in the spring, peak in Feb-May </li></ul></ul>
  5. 5. PATHOGENESIS AND PATHOLOGY <ul><li>Portal of entry </li></ul><ul><ul><li>Respiratory tract and regional lymph nodes </li></ul></ul><ul><ul><li>Enters bloodstream (primary viraemia)  monocyte – phagocyte system  target organs (secondary viraemia) </li></ul></ul><ul><li>Target organs </li></ul><ul><ul><li>The skin; the mucous membranes of the nasopharynx, </li></ul></ul><ul><li>bronchi, and intestinal tract; and in the conjunctivae , ect </li></ul><ul><li>Resulting In----- </li></ul><ul><li>1) Koplik spots and skin rash: serous exudation and proliferation of endothelial cells of the capillaries , vasculitis </li></ul><ul><li>2) Conjunctivis </li></ul>
  6. 6. PATHOGENESIS AND PATHOLOGY <ul><li>3) Laryngitis, croup, bronchitis :general inflammatory reaction </li></ul><ul><li>4) Hyperplasia of lymphoid tissue: multinucleated giant cells (Warthin-Finkeldey reticuloendothelial giant cells) may be found </li></ul><ul><li>5) Interstitial pneumonitis: Hecht giant cell pneumonia . </li></ul><ul><li>6) Bronchopneumonia: due to secondary bacterial infections </li></ul><ul><li>7) Encephalomyelitis: perivascular demyelinization occurs in areas of the brain and spinal cord. </li></ul><ul><li>8) Subacute sclerosing panencephalitis(SSPE): </li></ul><ul><li>degeneration of the cortex and white matter with intranuclear and intracytoplasmic inclusion bodies </li></ul>
  7. 7. CLINICAL MANIFESTATION <ul><li>Typical Manifestation: </li></ul><ul><li>patients havn’t had measles immunization, or vaccine failure with normal immunity or those havn’t used immune globulin </li></ul><ul><li>1. Incubation period (infection to symptoms) : </li></ul><ul><li>6-18days (average 10 days) </li></ul><ul><li>2. Prodromal period: </li></ul><ul><ul><li>3-4 days </li></ul></ul><ul><ul><li>Non-specific symptoms: fever, malaise, anorexia, headache </li></ul></ul><ul><ul><li>Classical triad: cough, coryza, conjunctivitis (with </li></ul></ul><ul><ul><li>photophobia, lacrimation) </li></ul></ul>
  8. 8. CLINICAL MANIFESTATION <ul><li>Enanthem (Koplik spots): </li></ul><ul><ul><li>Pathognomonic for measles </li></ul></ul><ul><ul><li>24-48 hr before rash appears </li></ul></ul><ul><ul><li>1mm, grayish white dots with </li></ul></ul><ul><ul><li>slight, reddish areolae </li></ul></ul><ul><ul><li>Buccal mucosa, opposite the </li></ul></ul><ul><ul><li>lower 2 nd molars </li></ul></ul><ul><ul><li>fade soon after rash onset </li></ul></ul>
  10. 10. CLINICAL MANIFESTATION <ul><li>3. Rash period </li></ul><ul><li>3-4days </li></ul><ul><li>Exanthem: </li></ul><ul><li>Erythematous, non-pruritic, maculopapular </li></ul><ul><ul><li>Upper lateral of the neck, behind ears, hairline, </li></ul></ul><ul><ul><li>face  trunk  arms and legs </li></ul></ul><ul><ul><li>The severity of the disease is directly related to </li></ul></ul><ul><ul><li>the extent and confluence of the rash </li></ul></ul><ul><ul><li>, </li></ul></ul>
  14. 14. CLINICAL MANIFESTATION <ul><ul><li>Temperature: </li></ul></ul><ul><ul><li>Rises abruptly as the rash appears </li></ul></ul><ul><ul><li>Reaches 40℃ or higher </li></ul></ul><ul><ul><li>Settles after 4-5 days – if persists, suspect secondary </li></ul></ul><ul><ul><li>infection </li></ul></ul><ul><ul><li>Coryza, fever, and cough : </li></ul></ul><ul><ul><li>Increasingly severe up to the time the rash has covered the </li></ul></ul><ul><ul><li>body </li></ul></ul><ul><ul><li>Lymphadenopathy (posterior cervical region, mesenteric) splenomegaly, diarrhoea, vomiting </li></ul></ul><ul><li>Chest X ray: </li></ul><ul><ul><li>May be abnormal, even in uncomplicated cases </li></ul></ul>
  15. 15. CLINICAL MANIFESTATION <ul><ul><li>4. Recovery period </li></ul></ul><ul><ul><li>3-4days </li></ul></ul><ul><ul><li>Exanthem: </li></ul></ul><ul><ul><li>Fades in order of appearance </li></ul></ul><ul><ul><li>Branny desquamation and brownish discoloration </li></ul></ul><ul><ul><li>Entire illness – 10 days </li></ul></ul>
  17. 17. CLINICAL MANIFESTATION <ul><li>Atypical Manifestation: </li></ul><ul><li>1. Mild measles </li></ul><ul><li>In patients: administered immune globulin products during the incubation period and immunized against measles; in infants <8mo </li></ul><ul><li>Long incubation period and short prodromal phase </li></ul><ul><li>Mild symptom </li></ul><ul><li>No Koplik spot </li></ul><ul><li>The rash tends to be faint </li></ul><ul><li>No branny desquamation and brownish discoloration occur as the rash fades </li></ul><ul><li>No complications and short course </li></ul>
  18. 18. CLINICAL MANIFESTATION <ul><li>2. Severe measles: </li></ul><ul><li>In cases with malnutrition, hypoimmunity and secondary </li></ul><ul><li>infection </li></ul><ul><li>Persistent hyperpyrexia, sometimes with convulsions and even </li></ul><ul><li>coma </li></ul><ul><li>Exanthem: </li></ul><ul><li>Completely covered the skin </li></ul><ul><li>Confluent, petechiae, ecchymoses </li></ul><ul><li>The hemorrhagic type of measles (black measles), bleeding </li></ul><ul><li>may occur from the mouth, nose, or bowel. disseminated </li></ul><ul><li>intravascular coagulation (DIC) </li></ul>
  20. 20. CLINICAL MANIFESTATION <ul><li>3. Atypical measles syndroma: </li></ul><ul><li>Recipients of killed measles virus vaccine, who later come in </li></ul><ul><li>contact with wild-type measles virus. </li></ul><ul><li>Distinguished by high fever, severe headache, severe abdominal </li></ul><ul><li>pain, often with vomiting, myalgias, respiratory symptoms, </li></ul><ul><li>pneumonia with pleural effusion </li></ul><ul><li>Exanthem: </li></ul><ul><li>First appears on the palms, wrists, soles, and ankles, and </li></ul><ul><li>progresses in a centripetal direction. </li></ul><ul><li>Maculopapular  vesicular  purpuric or hemorrhagic. </li></ul><ul><li>Koplik spots rarely appear </li></ul>
  21. 21. CLINICAL MANIFESTATION Atypical measles syndroma
  22. 22. CLINICAL MANIFESTATION <ul><li>4. Measles absent of rush </li></ul><ul><li>Immunodepressed, or passive immunized recently cases and </li></ul><ul><li>occasionally in infants <9mo who have appreciable levels </li></ul><ul><li>of maternal antibody </li></ul><ul><li>Non-specificity </li></ul><ul><li>Difficult to diagnosis </li></ul>
  23. 23. COMPLICATIONS <ul><ul><ul><li>1. Respiratory Tract </li></ul></ul></ul><ul><ul><ul><li>Laryngitis, tracheitis, bronchitis – due to measles itself </li></ul></ul></ul><ul><ul><ul><li>Laryngotrachobronchitis (croup) –cause airway obstruction to require tracheostomy </li></ul></ul></ul><ul><ul><ul><li>Secondary pneumonia – immunocompromised, malnourished patients. pneumococcus, group A </li></ul></ul></ul><ul><ul><ul><li>Streptococcus, Staphylococcus aureus and </li></ul></ul></ul><ul><ul><ul><li>Haemophilus influenzae type B. </li></ul></ul></ul><ul><ul><ul><li>Exacerbation of TB </li></ul></ul></ul>
  24. 24. COMPLICATIONS <ul><li>2. Myocarditis </li></ul><ul><li>3. Malnutrition and Vitamin A deficiency </li></ul>
  25. 25. COMPLICATIONS <ul><li>4. CNS </li></ul><ul><li>The incidence of encephalomyelitis is 1-2/l,000 cases of measles </li></ul><ul><li>Onset occurs 2-5 days after the appearance of the rash </li></ul><ul><li>No correlation between the severity of the rash illness and </li></ul><ul><li>that of the neurologic involvement </li></ul><ul><ul><li>Earlier - direct viral effect in CNS </li></ul></ul><ul><ul><li>Later – immune response causing demyelination </li></ul></ul><ul><ul><li>Significant morbidity, permanent sequelae – mental </li></ul></ul><ul><ul><li>retardation and paralysis </li></ul></ul><ul><li>Subacute sclerosing panencephalitis (SSPE): extremely rare, 6-10 years after infection. Progressive dementia, fatal. Interaction of host with defective form of virus </li></ul>
  26. 26. LABORATORY EXAMINATION <ul><li>Isolation of measles virus from a clinical specimen (e.g., nasopharynx, urine) </li></ul><ul><li>Significant rise in measles IgG by any standard serologic assay </li></ul><ul><li>Positive serologic test for measles IgM antibody </li></ul><ul><li>Immunofluorescence detects Measles antigens </li></ul><ul><li>Multinucleated giant cells in smears of nasal mucosa </li></ul><ul><li>Low white blood cell count and a relative lymphocytosis in PB </li></ul><ul><li>Measles encephalitis – raised protein, lymphocytes in CSF </li></ul>
  27. 27. DIAGNOSIS <ul><li>characteristic clinical picture: </li></ul><ul><li>Measles contact </li></ul><ul><li>Koplik spot </li></ul><ul><li>Features of the skin rash </li></ul><ul><li>The relation between the eruption and fever </li></ul><ul><li>Laboratory confirmation is rarely needed </li></ul>
  28. 28. DIFFERENTIAL DIAGNOSIS <ul><li>The rash of measles must be differentiated from that of </li></ul><ul><li>rubella; </li></ul><ul><li>roseola intantum; </li></ul><ul><li>enteroviral infections; </li></ul><ul><li>scarlet fever; </li></ul><ul><li>and drug rashes. </li></ul>
  29. 29. Pathogen Features Rash fever Vs Rash Measles Measles virus Cough coryza, conjunctivitis Red maculopapule fever for3-4days Koplik spot after the Face  trunk  limbs rises abruptly as 2nd -3rd fever Desquamation and the rash appears discoloration Rubella Rubella virus Disease is mild, postau- Maculopapule fever for1-2days ricular lymphadenopathy Face  trunk  limbs low or absent No desquamation and during the rash discoloration Roseola Human Generally well, Seizures Rose colored, spreads high fever for3-5 Infantum herpesvirus 6 (5-10%) due to high to the neck and the days, ceases with fever trunk the onset of rash Scarlet fever Group A High fever, toxicity, Gooseflesh texture on fever for1-2days Streptococcus Angina, strawberry tongue an erythematous base higher as the Circumoral pallor, tonsillitis for 3-5 day, desquam- rash appears ation after 1 week Enteroviral Echovirus, Accompanied by respiratory Scattered macule or Rash appears Infections Coxsackievirus or gastrointestinal maculopapule, few during or after manifestation confluent, 1-3 days, fever no desquamation Drug Rash Manifestations of Urticarial, maculopapula Relates to the primary disease, itching or scarlatiniform rash drugs taken
  30. 30. DIFFERENTIAL DIAGNOSIS Scarlet fever
  31. 31. DIFFERENTIAL DIAGNOSIS Scarlet fever
  32. 32. TREATMENT <ul><li>Supportive, symptom-directed </li></ul><ul><li>Antipyretics for fever </li></ul><ul><li>Bed rest </li></ul><ul><li>Adequate fluid intake </li></ul><ul><li>Be protected from exposure to strong light </li></ul><ul><li>Antibiotics for otitis media, pneumonia </li></ul><ul><li>High doses Vitamin A in severe/ potentially severe measles/ patients less than 2 years </li></ul><ul><li>100,000IU—200,000IU </li></ul>
  33. 33. PREVENTION <ul><li>1. Quarantine period </li></ul><ul><li>5 days after rash appears, longer for complicated measles </li></ul><ul><li>2. Vaccine </li></ul><ul><li>The initial measles immunization is recommended at 8mo of </li></ul><ul><li>age </li></ul><ul><li>A second immunization is recommended routinely at 7yr of </li></ul><ul><li>age </li></ul><ul><li>3. Postexposure Prophylaxis </li></ul><ul><li>Passive immunization with immune globulin (0.25mL/kg) </li></ul><ul><li>is effective for prevention and attenuation of measles within </li></ul><ul><li>5 days of exposure. </li></ul>
  34. 34. THANK YOU