This document discusses measles, an acute viral infection characterized by a maculopapular rash. It covers the etiology (measles virus), epidemiology (endemic worldwide, peak incidence in children 5-10 years old), transmission (highly contagious via respiratory droplets), clinical features (incubation 10-12 days, prodrome of fever and cough, pathognomonic Koplik's spots, spreading rash), diagnosis (clinical features or measles IgM antibodies), and differential diagnosis (must be differentiated from other rashes). Measles is a significant cause of mortality and morbidity in developing countries.

1. Measles
PRESENTED BY
BEEMAMOL HUSSAIN
ASWINI K S
40TH BSC NURSING
GOVERNMENT COLLEGE OF NURSING
KOZHIKODE

2. Measles
• 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 and catarrhal symptoms of URT.

4. Etiology
• Measles virus, the cause of measles, is an RNA virus of the
genus Morbillivirus in the family Paramyxoviridae.
• Only one serotype is known
• It is rarely subclinical .

5. Epidemiology
• 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 (3 yr interval in India)
as new groups of susceptible children were exposed
• When introduced into a virgin community more than 90% of that
community will be infected.

6. • Prior to the use of measles vaccine, the peak incidence was
among children 5-10 yr of age.
• Disease has high mortality and morbidity in developing
countries

7. Incidence

8. Epidemiological determinants
• Agent factors
AGENT : paramyxo virus
Cannot survive outside human body
SOURCE OF INFECTION : A case of measles
carriers are not known to occur
subclinical measles occur more often.
INFECTIVE MATERIAL : Secretion of the nose, throat and respiratory
tract of a case of measles.

9. COMMUNICABILITY : Highly infectious during prodomal period and
eruption
declines rapidly after appearance of rash.
SECOND ATTACK RATE : There is only one antigenic type of measles
virus
infection confers lifelong immunity

10. • Host factors
AGE : Infancy or childhood (6 months to 3 years of age)
SEX : Incidence equal
IMMUNITY : No inborn immunity. Immunity conferred only by attack of
measles

11. NUTRITION : Tends to be severe in the malnourished Children
Carrying a mortality upto 400 times higher than in well nourished children having
measles.
May be related to poor cell meditated immune response secondary to malnutrition
Additionally severely malnourished have been shown to excrete measles virus for
longer periods.
An attack of severe measles may be followed by weight loss precipitating the
child into malnutrition.

12. Transmission
• Measles is highly contagious ; directly from person to person
• Maximal dissemination of virus occurs by droplet infection and
droplet nuclei during the prodromal period ( catarrhal stage ).

13. • Transmission to susceptible contacts often occurs prior to
diagnosis of the index case
• Portal of entry is respiratory tract
• Infection through conjunctiva is considered likely
• Recipients of vaccine are non-contagious to others

14. Pathogenesis
• 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

15. • 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

16. • 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

17. • Interstitial pneumonitis resulting from measles virus takes the
form of Hecht giant cell pneumonia .
• Bronchopneumonia may occur from secondary bacterial
infection

18. Clinical features
1. Incubation stage
2. Prodromal stage
3. Eruptive stage
4. Post measles stage

19. Incubation period
• 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

20. Predomal phase
• 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

21. • The conjunctival inflammation and photophobia may suggest
measles before Koplik spots appear.
• .

22. Koplicks spot
• An enanthem or red mottling is usually present on the hard and soft
palates
• the pathognomonic sign of measles
• 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.
• 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

24. Predomal phase (cont.)
• 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.

25. • 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.

26. Eruptive stage
Usually starts as faint macules on the:
 upper lateral parts of the neck
 behind the ears
 along the hairline
 posterior parts of the cheek .

27. The rash
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 <

29. • 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.

30. • 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

31. • 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

32. • 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

33. • 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

34. • Itching is generally slight .
• As the rash fades , branny desquamation and brownish
discoloration occur and then disappear within 7-10 days.

35. 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.

36. • 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

37. • 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

38. • 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.

39. • The rash of rubeola must be differentiated from that of:
• 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