Measles

Measles
(Morbilli, Rubeolla)
Mr. Kuldeep Vyas
Asst. Prof. Community Health
Nursing11-06-20 1Kuldeep Vyas M.Sc. N. CHN

Measles (Rubeola)
11-06-20 2
It is an acute viral infection characterized by
a final stage with a maculopapular rash
erupting successively over the neck and
face, trunk, arms, and legs, and
accompanied by a high fever.
Kuldeep Vyas M.Sc. N. CHN

Etiology
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

Measles virus, the cause of measles, is
an RNA virus of the genus
Morbillivirus in the family
Paramyxoviridae.
Only one serotype is known

Epidemiology
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

Measles is endemic throughout the
world.
In the past, epidemics tended to occur
irregularly, appearing in the spring
in large cities at 2-4-yr intervals as
new groups of susceptible children
were exposed.

Epidemiology (Cont.)
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

It is rarely subclinical.
Prior to the use of measles
vaccine, the peak incidence was
among children 5-10 yr of age.

Epidemiology (Cont.)
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 Individuals born before 1957 are
considered to have had natural infection
and to be immune

TRANSMISSION
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

Measles is highly contagious;
approximately 90% of susceptible
household contacts acquire the disease.
Maximal dissemination of virus occurs
by droplet spray during the prodromal
period (catarrhal stage).

TRANSMISSION (Cont.)
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

Transmission to susceptible contacts often
occurs prior to diagnosis of the index case
Infants acquire immunity transplacentally
from mothers who have had measles or
measles immunization.

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

This immunity is usually complete for
the first 4-6 mo of life and wanes at a
variable rate.
Some protection persists that may
interfere with immunization
administered before 12 mo of age.

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 Most women of childbearing age in
the United States now have measles
immunity by means of immunization
rather than disease

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 infants of mothers with measles
vaccine-induced immunity lose
passive antibody at a younger age
than infants of mothers who had
measles infection.

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 Infants of mothers who are susceptible to
measles have no measles immunity and may
contract the disease simultaneously with the
mother before or after delivery

Pathogenesis
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

The essential lesion of measles is found in
the skin, conjunctivae, and the mucous
membranes of the nasopharynx, bronchi,
and intestinal tract.
Serous exudate and proliferation of
mononuclear cells and a few
polymorphonuclear cells occur around
the capillaries.

Pathogenesis (cont.)
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
 Hyperplasia of lymphoid tissue usually
occurs, particularly in the appendix,
where multinucleated giant cells of up to
100 μm in diameter (Warthin- Finkeldey
reticuloendothelial giant cells) may be
found.
In the skin, the reaction is
particularly notable about the
sebaceous glands and hair follicles.

 Koplik spots consist of serous exudate
and proliferation of endothelial cells
similar to those in the skin lesions.
 A general inflammatory reaction of the
buccal and pharyngeal mucosa extends
into the lymphoid tissue and the
tracheobronchial mucous membrane.
11-06-20 15Kuldeep Vyas M.Sc. N. CHN

11-06-20 16


Interstitial pneumonitis resulting
from measles virus takes the form of
Hecht giant cell pneumonia.
Bronchopneumonia may occur from
secondary bacterial infection.

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

In fatal cases of encephalomyelitis,
perivascular demyelinization occurs in
areas of the brain and spinal cord.
In subacute sclerosing panencephalitis
(SSPE), there may be degeneration of the
cortex and white matter with
intranuclear and intracytoplasmic
inclusion bodies

 Measles has three clinical stages:
1. an incubation stage
2. a prodromal stage with an enanthem
(Koplik spots) and mild symptoms
3. a final stage with a maculopapular
rash accompanied by high fever.
ClinicalManifestations

Koplik’s spots

Head and shoulders of boy with measles

Measles

Measles rash and conjunctivitis

The incubationperiod
 lasts approximately 10-12 days to the first
prodromal symptoms and another 2-4 days to
the appearance of the rash; rarely, it may be as
short as 6-10 days.
 Body temperature may increase slightly 9-10
days from the date of infection and then
subside for 24 hr or so.
 The patient may transmit the virus by the 9th-
10th day after exposure and occasionally as
early as the 7th day, before the illness can be
diagnosed

The prodromal phase
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

usually lasts 3-5 days and is characterized by:
* low-grade to moderate fever
* dry cough
* coryza
* conjunctivitis.
These symptoms nearly always precede the
appearance of Koplik spots, the pathognomonic
sign of measles, by 2-3 days.

The prodromal phase(cont.)
11-06-20 28


The conjunctival inflammation and
photophobia may suggest measles before
Koplik spots appear.
In particular, a transverse line of conjunctival
inflammation, sharply demarcated along the
eyelid margin, may be of diagnostic assistance in
the prodromal stage. As the entire conjunctiva
becomes involved, the line disappears.

Koplikspots
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
 An enanthem or red mottling is
usually present on the hard and soft
palates
the pathognomonic sign of
measles:

Koplik spots(cont.)
are grayish white dots, usually as
small as grains of sand, that have
slight, reddish areolae; occasionally
they are hemorrhagic.
tend to occur opposite the lower molars
but may spread irregularly over the rest
of the buccal mucosa.

Koplik spots(cont.)
 Rarely they are found within the
midportion of the lower lip, on the
palate, and on the lacrimal caruncle.
They appear and disappear rapidly,
usually within 12-18 hr.
As they fade, a red, spotty
discoloration of the mucosa may
remain.

 Occasionally, the prodromal phase may be
severe, being ushered in by a sudden high
fever, sometimes with convulsions and even
pneumonia.
 Usually the coryza, fever, and cough are
increasingly severe up to the time the rash
has covered the body.
The temperature rises abruptly as the rash
appears and often reaches 40°C (104°F) or
higher.

In uncomplicated cases, as the rash appears
on the legs and feet, the symptoms subside
rapidly within about 2 days, usually with an
abrupt drop in temperature to normal.
Patients up to this point may appear
desperately ill, but within 24 hr after the
temperature drops, they appear well.

The rash
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 usually starts as faint macules on the:
* upper lateral parts of the neck
* behind the ears
* along the hairline
* posterior parts of the cheek.

The rash (cont.)
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 The individual lesions become increasingly
maculopapular as the rash spreads rapidly
over the:
* entire face
* neck
* upper arms
* upper part of the chest
within approximately the first 24 hr

Maculopapular rash of measles

The rash (cont.)
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

During the succeeding 24 hr the rash
spreads over the back, abdomen, entire
arm, and thighs.
As it finally reaches the feet on the
2nd-3rd day, it begins to fade on the
face.

Typical rash on day 2–3 of measles

Rash on day 5 of measles showing typical confluence and density
11-06-20 39
on head with scattered lesions on the trunk.

The rash (cont.)
The rash fades downward in the same
sequence in which it appeared.
 The severity of the disease is directly related to
the extent and confluence of the rash.
 In mild measles the rash tends not to be
confluent, and in very mild cases there are
few, if any, lesions on the legs.

The rash (cont.)
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

In severe cases the rash is confluent, the
skin is completely covered, including the
palms and soles, and the face is swollen
and disfigured.
The rash is often slightly hemorrhagic; in
severe cases with a confluent rash,
petechiae may be present in large
numbers, and there may be extensive
ecchymoses

The rash (cont.)
 The appearance of the rash may vary
markedly.
Infrequently a slight urticarial, faint
macular, or scarlatiniform rash may
appear during the early prodromal stage,
disappearing in advance of the typical
rash.

The rash (cont.)
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 Complete absence of rash is rare except :
1. in patients who have received
immunoglobulin (Ig) during the incubation
period
2. in some patients with HIV infection
3. occasionally in infants younger than 9 mo of
age who have appreciable levels of maternal
antibody.

The rash (cont.)
11-06-20 44


In the hemorrhagic type of measles
(black measles), bleeding may occur
from the mouth, nose, or bowel.
In mild cases the rash may be less macular
and more nearly pinpoint, somewhat
resembling that of scarlet fever or rubella

The rash (cont.)
11-06-20 45


Itching is generally slight.
As the rash fades, branny desquamation
and brownish discoloration occur and then
disappear within 7-10 days.

The prodromal phase (cont.)
11-06-20 46



Otitis media
bronchopneumonia
gastrointestinal symptoms such as
diarrhea and vomiting
Are more common in infants and small
children (especially if they are
malnourished) than in older children.

Diagnosis
 The diagnosis is usually apparent from the
characteristic clinical picture; laboratory
confirmation is rarely needed
Testing for measles IgM antibodies is
recommended in some situations
Measles IgM is detectable for 1 mo after illness,
but sensitivity of IgM assays may be limited in the
first 72 hr of the rash illness.

Diagnosis (cont.)
11-06-20 48



Isolation of measles virus from clinical samples is
also useful in identifying the genotype of the
strain to track transmission patterns.
All suspected measles cases should be
reported immediately to local or health
departments.
During the prodromal stage multinucleated
giant cells can be demonstrated in smears of
the nasal mucosa.

Diagnosis (cont.)
Antibodies become detectable when the rash
appears;
testing of acute and convalescent sera
demonstrates the diagnostic seroconversion or
fourfold increase in titer.
Measles virus can be isolated by tissue
culture in human embryonic or rhesus
monkey kidney cells.

Diagnosis (cont.)
Cytopathic changes, visible in 5-10 days,
consist of multinucleated giant cells with
intranuclear inclusions.
The white blood cell count tends to be low
with a relative lymphocytosis
 Cerebrospinal fluid in patients with measles
encephalitis usually shows an increase in
protein and a small increase in lymphocytes.
The glucose level is normal.

The rash of rubeola must be differentiated from that of:
11-06-20 51











Rubella
Roseola infantum (human herpesvirus 6)
Infections resulting from:
* echovirus * coxsackievirus * adenovirus
Infectious mononucleosis
Toxoplasmosis
Meningococcemia
Scarlet fever
Rickettsial diseases
Kawasaki disease
Serum sickness
Drug rashes

Treatment
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




There is no specific antiviral therapy;
treatment is entirely supportive.
Antipyretics (acetaminophen or
ibuprofen) for fever
bed rest
maintenance of an adequate fluid
intake
are indicated.

Treatment (cont.)
11-06-20 53



Humidification may alleviate symptoms of laryngitis or
an excessively irritating cough; it is best to keep the
room comfortably warm rather than cool.
Patients with photophobia should be protected from
exposure to strong light.
Bacterial complications of otitis media and
bronchopneumonia require appropriate antimicrobial
therapy.

Treatment (cont.)
11-06-20 54




Complications such as encephalitis, subacute sclerosing
panencephalitis, giant cell pneumonia, and disseminated
intravascular coagulation must be assessed individually.
Good supportive care is essential.
Immunoglobulin and corticosteroids are of limited
value.
Currently available antiviral compounds are not
effective.

Treatment (cont.)
the American Academy of Pediatrics recommends
consideration of vitamin A supplementation for:
children 6 mo to 2 yr of age who are hospitalized
for measles and its complications
children older than 6 mo of age with measles and
immunodeficiency;
11-06-20 55




Treatment (cont.)
11-06-20 56




The recommended regimen is a single dose of:
100,000 IU orally for children 6 mo to 1 yr
200,000 IU for children 1 yr of age or older
Children with ophthalmologic evidence of
vitamin A deficiency should be given additional
doses the next day and 4 wk later.

Complications
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 The chief complications of measles
are:



otitis media
pneumonia
encephalitis.

Respiratory tract complications
11-06-20 58



Interstitial pneumonia may be caused by the
measles virus (giant cell pneumonia).
Bacterial superinfection and bronchopneumonia are
more frequent, however, usually with pneumococcus,
group A Streptococcus, Staphylococcus aureus, and
Haemophilus influenzae type b.
Laryngitis, tracheitis, and bronchitis are common
and may be due to the virus alone

Respiratory tract complications
11-06-20 59



Measles may exacerbate underlying
Mycobacterium tuberculosis infection
There may also be a temporary loss of
hypersensitivity reaction to tuberculin
skin testing.
Measles pneumonia in HIV-infected
patients is often fatal and is not always
accompanied by rash

Cardiovascular complications
11-06-20 60


Noma of the cheeks may occur in rare instances
Gangrene elsewhere appears to be secondary to :
purpura fulminans disseminated intravascular
coagulation following measles
 Myocarditis is an infrequent serious complication,
although transient electrocardiographic changes may be
relatively common.

Neurologic complications
11-06-20 61
 Are more common in measles than in any of the other
exanthematous diseases.
Encephalomyelitis

 The incidence is estimated to be 1-2/1,000 cases of
measles.
There is no correlation between the severity of the :
* Rash illness and that of the neurologic involvement
* Initial encephalitic process and the prognosis.

Neurologic complications (cont.)
11-06-20 62



Infrequently, encephalitic involvement is manifest in the
pre-eruptive period, but more often its onset occurs 2-5
days after the appearance of the rash.
The cause of measles encephalitis remains
controversial.
1. Encephalitis early in the course of the disease :
direct viral invasion may be operative for
2. Encephalitis that occurs later is predominantly
demyelinating and may reflect an immunologic reaction.
Fatal encephalitis has occurred in children receiving
immunosuppressive treatment.

Neurologic complications (cont.)
11-06-20 63
 Other central nervous system complications,
including:
 Guillain-Barré syndrome
 Hemiplegia
 Cerebral thrombophlebitis
 Retrobulbar neuritis
occur rarely.

Prognosis
11-06-20 64
 Case fatality rates in the United States have
decreased in recent years to low levels for all
age groups, largely because of:
Improved socioeconomic conditions
 Effective antibacterial therapy for the

treatment of secondary bacterial infections.
Despite the decline in measles cases and
fatalities in the United States, the case fatality
rate is still 1-3/1,000 cases.

Prognosis (cont.)
11-06-20 65



Deaths are primarily due to pneumonia or
secondary bacterial infections.
In developing countries measles frequently
occurs in infants; possibly because of
concomitant malnutrition, the disease is very
severe in these locations and has a high
mortality.
When measles is introduced into a highly
susceptible population, the results may be
disastrous.

Prevention
Isolation precautions, especially in
hospitals and other institutions, should
be maintained from the 7th day after
exposure until 5 days after the rash has
appeared.
11-06-20 66


VACCINE
11-06-20 67


The initial measles immunization, usually as
measles-mumps-rubella (MMR) vaccine, is
recommended at 12-15 mo of age
MMR vaccine may be given for:
1. Measles postexposure
2. Outbreak prophylaxis as early as 6 mo
of age.

VACCINE (cont.)
11-06-20 68



A second immunization, also as MMR, is
recommended routinely at 4-6 yr of age
MMR may be administered at any time during
childhood provided at least 4 wk have elapsed since the
first dose.
Second measles immunization should be given to :
1. Children who have not previously received the
second dose should be immunized by 11-12 yr of
age.
2.Adolescents entering college or the workforce

VACCINE (cont.)
A tuberculin test prior to or concurrent
with active immunization against measles
is desirable if tuberculosis is under
consideration.
11-06-20 69


VACCINE (cont.)
11-06-20 70
* Measles vaccine is not recommended for:
1. Pregnant women
2. Children with primary immunodeficiency
3. Untreated tuberculosis, cancer, or organ
transplantation
4. Those receiving long-term immunosuppressive
therapy
5. severely immunocompromised HIV-infected
children

VACCINE (cont.)
11-06-20 71
 HIV-infected children without:
1. Severe immunosuppression
2.Evidence of measles immunity
may receive measles vaccine.

POSTEXPOSURE PROPHYLAXIS
11-06-20 72


Passive immunization with immune globulin is
effective for prevention and attenuation of measles
within 6 days of exposure.
Susceptible household and hospital contacts who
are:
1. younger than 12 mo of age
2. pregnant
should receive immune globulin (0.25 mL/kg;
maximum: 15 mL) intramuscularly as soon as
possible after exposure, but within 5 days.

POSTEXPOSURE PROPHYLAXIS (cont.)
Immunocompromised persons should receive
immune globulin (0.5 mL/kg; maximum: 15 mL)
intramuscularly regardless of immunization
status.
Infants 6 mo of age or younger born to
nonimmune mothers should receive immune
globulin;
Infants 6 mo of age or younger born to immune
mothers are considered protected by maternal
antibody.
11-06-20 73




POSTEXPOSURE PROPHYLAXIS (cont.)
11-06-20 74



Susceptible children 6-12 mo of age should
also be vaccinated; this vaccination does not
count as one of the two required measles
vaccinations.
Susceptible children 12 mo of age or older
should receive vaccine alone within 72 hr.
Pregnant women and immunocompromised
persons should receive immune globulin but
not vaccine

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