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measles (1st disease)

Etiology: - infection with measles virus (rubeola) Epidemiology: - Americas declared free of measles [15] - transmission by aerosolized respiratory droplets - progress in elimination of measles & rubella 2000-2011 [5] - outbbreaks in New York & Calfornia in 2014 [6,7] - outbreak Minnesota, April-May 2016 [18] - 155 cases annually in USA 2010-2013 [7] - 644 cases & 23 outbreaks in 2014 U.S.A. [CDC] - 288 cases of measles from 18 states & New York City Jan 1- May 23 of 2014 [8] - most in unvaccinated (69%) or with unknown vaccination status (20%) - thus at least 11% of cases in vaccinated individuals - 154 cases (17 states) Jan 1 through Feb 20, 2015 in U.S. [CDC] - travelers returning from high-risk areas - case of missionary retruning from the Philippines [12] - 42% of measles cases 2000-2015 occurred in people who were unvaccinated because of nonmedical exemptions [14] - small decline in vaccination rate could triple number of measles cases [19] - measles cases increased 4-fold in Europe from 2016 to 2017 [20] - Romania, Italy, & the Ukraine with largest outbreaks - 34,000 cases of measles reported in Europe in 1st 2 months of 2019 [23] - majority of cases are reported in Ukraine (25,000) - 13 measles-related deaths in 3 countries (Albania, Romania, Ukraine) - 2 cases of measles reported in travelers from abroad in U.S. airports March 2018, one case in Detroit on March 6, the other in Newark NJ on March 12 from Brussels, subsequently traveling to Memphis TN [21] - reported cases of measles increased more than 30% globally from 2016 to 2017 [22] - January 1, 2020-March 28, 2024, a total of 338 U.S. measles cases were reported; 29% of these cases occurred during the first quarter of 2024 [27] - almost all persons were unvaccinated or vaccination status was unknown [27] Pathology: - induces immunosuppression due to depletion of lymphocytes - both B-cell & T-cell depletion - effects extend over 2-3 years [10]* * proposed mechanism for observed protection against infection by different organisms by measles vaccine [10] Clinical manifestations: 1) incubation period 8-12 days 2) prodromal symptoms of coryza, conjunctivitis, photophobia, fever, malaise & cough for 2-4 days 3) Koplik's spots appear in the prodromal phase 4) exanthem phase a) rash [12] 1] begins at hairline on forehead & behind ears then spreads down the body 2] initially erythematous & maculopapular then becomes confluent in the same progression as spread - lesions are not vesicular [11] 3] resolution in same progression as spread (head down) 4] rash begins to fade & turn brown in 3-4 days 5] resolution in 1 week b) fever [12] c) upper respiratory symptoms, rhinorrhea [12] d) cough [12] e) sore throat f) diarrhea g) nausea/vomiting h) abdominal pain 5) atypical measles a) Koplick's spots unusual b) rash 1] initially erythematous & maculopapular 2] 1st appears on the hands & feet, then spreads upward 3] particularly prominent on wrists & ankles c) pneumonia with pleural effusion d) high fever 6) images [17] * distinguishing feature from varicella [11] Laboratory: 1) viral culture is the definitive test 2) serology: a) measles-specific IgM elevated [12] b) serial antibody titers (hemagglutination inhibition or complement-fixation) will show a 4-fold rise c) measles virus IgG negative [12] 3) serum transaminases may be elevated [12] 4) complete blood count: - leukopenia & thrombocytopenia may be noted [12] 3) see ARUP consult [2] Radiology: chest X-ray in cases of atypical measles Differential diagnosis: 1) infectious mononucleosis 2) Mycoplasma pneumonia 3) drug eruptions 4) Rocky Mountain spotted fever Complications: 1) pneumonia a) bronchiolitis in infants b) secondary bacterial pneumonia may occur 2) otitis media: more common in young children 3) laryngitis/laryngotracheitis 4) myocarditis 5) pericarditis 6) encephalitis (rare 0.05- 0.1%) - subacute sclerosing panencephalitis (0.17% in infants) [16] 7) thrombocytopenic purpura 8) severe, often fatal complications may occur in immunocompromised hosts 10) not teratogenic, but associated with increased perinatal mortality & spontaneous abortion 11) seconary infections due, in part, to diminished pre-existing antibodies [25] Management: 1) no specific therapy for uncomplicated measles 2) pharmacologic agents a) vitamin A 200,000 IU (60 mg) on the 1st 2 days of hospitalization may reduce morbidity & mortality in children admitted with complications of croup, pneumonia, or diarrhea - vitamin A administered to 54 year old adult [12] b) acetaminophen for fever, headache, sore throat c) antitussive agents for cough 3) liberal fluid intake 4) rest 5) isolation from susceptible persons 6) prophylaxis: 1) MMR vaccine 2) immune globulin 0.25 mL/kg (15 mL max dose) when a susceptible individual has definite exposure a) given within 5 days may prevent infection b) given after 5 days will reduce severity c) should be administered to 1] HIV-infected children regardless of vaccination status if a definite exposure occurred 2] infants < 7 months of age who've been exposed to measles 3] severely immunocompromised persons 4] pregnant women who have been exposed to measles without evidence of immunity [3] 3) 82% of cases occur in unvaccinated individuals [4]

Related

Koplik's spot measles virus (rubeola) measles, mumps & rubella combined vaccine (MMR)

General

viral infection childhood exanthem (numbered diseases)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 870-71
  2. ARUP Consult: Measles Virus - Rubeola The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/measles-virus
  3. McLean HQ et al Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. June 14, 2013 / 62(RR04);1-34 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm
  4. Centers for Disease Control and Prevention Measles - United States, January 1 - August 24, 2013 MMWR. September 13, 2013 / 62(36);741-743 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a2.htm
  5. Papania MJ et al Elimination of Endemic Measles, Rubella, and Congenital Rubella Syndrome From the Western Hemisphere. The US Experience. JAMA Pediatr. Published online December 05, 2013. PMID: 24311021 http://archpedi.jamanetwork.com/article.aspx?articleid=1787786 - Grabowsky M The Beginning of the End of Measles and Rubella. JAMA Pediatr. Published online December 05, 2013 PMID: 24310954 http://archpedi.jamanetwork.com/article.aspx?articleid=1787785 - Centers for Disease Control and Prevention Rubella and Congenital Rubella Syndrome Control and Elimination - Global Progress, 2000=2012. MMWR. Weekly. December 6, 2013 / 62(48);983-986 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6248a3.htm
  6. New York City Department of Health and Mental Hygiene news release. March 7, 2104 Health Department Investigating Measles Outbreak in Northern Manhattan and the Bronx. http://www.nyc.gov/html/doh/html/pr2014/pr007-14.shtml
  7. Sammons JS Ready or Not: Responding to Measles in the Postelimination Era. Ann Intern Med. Published online 24 April 2014 PMID: 24763975 http://annals.org/article.aspx?articleid=1865449 - Centers for Disease Control and Prevention (CDC) Notes from the Field: Measles - California, January 1-April 18, 2014 MMWR Weekly. April 25, 2014 / 63(16);362-363 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6316a6.htm
  8. Gastanaduy PA et al Centers for Disease Control and Prevention (CDC) Measles - United States, January 1-May 23, 2014. MMWR. May 29, 2014 / 63(Early Release);1-4 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0529a1.htm?
  9. Low N et al. A randomized, controlled trial of an aerosolized vaccine against measles. N Engl J Med 2015 Apr 16; 372:1519 PMID: 25875257 http://www.nejm.org/doi/full/10.1056/NEJMoa1407417
  10. Mina MJ et al Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality. Science 8 May 2015. Vol. 348 no. 6235 pp. 694-699 PMID: 25954009 http://www.sciencemag.org/content/348/6235/694.short
  11. NEJM Knowledge+ May 12, 2105
  12. Lilly E, Srivastava B Images in clinical medicine. Measles. N Engl J Med. 2015 Jun 4;372(23):2217 PMID: 26039602 http://www.nejm.org/doi/full/10.1056/NEJMicm1407399
  13. Safdar N et al Clinical problem-solving. In sight and out of mind. N Engl J Med 2015; 372:2218-2223. June 4, 2015 PMID: 26039603 http://www.nejm.org/doi/full/10.1056/NEJMcps1413402
  14. Phadke VK, Bednarczyk RA, Salmon DA, Omer SB. Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United StatesA Review of Measles and Pertussis. JAMA. 2016;315(11):1149-1158 PMID: 26978210 http://jama.jamanetwork.com/article.aspx?articleid=2503179 - Davis MM Toward High-Reliability Vaccination Efforts in the United States. JAMA. 2016;315(11):1115-1117 PMID: 26978205 http://jama.jamanetwork.com/article.aspx?articleid=2503155
  15. Pan American Health Organization. Sept. 27, 2016 Region of the Americas is declared free of measles. http://www.paho.org/hq/index.php?option=com_content&view=article&id=12528:region-americas-declared-free-measles&Itemid=1926&lang=en
  16. Orciari Herman A, Sadoughi S, Sofair A Fatal Measles Complication Seems More Common Than Previously Believed. Physician's First Watch, Oct 31, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  17. Brady MP (images) Cutaneous and Mucosal Manifestations of Viral Diseases. Medscape. March 2017 http://reference.medscape.com/features/slideshow/viral-skin
  18. Hall V, Banerjee E, Kenyon C, et al. Measles Outbreak - Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep 2017;66:713-717 https://www.cdc.gov/mmwr/volumes/66/wr/mm6627a1.htm
  19. Lo NC, Hotez PJ Public Health and Economic Consequences of Vaccine Hesitancy for Measles in the United States. JAMA Pediatr. Published online July 24, 2017 PMID: 28738137 http://jamanetwork.com/journals/jamapediatrics/fullarticle/2643169
  20. World Health Organization (WHO) Europe observes a 4-fold increase in measles cases in 2017 compared to previous year. WHO Press Release. Copenhagen, 19 February 2018 http://www.euro.who.int/en/media-centre/sections/press-releases/2018/europe-observes-a-4-fold-increase-in-measles-cases-in-2017-compared-to-previous-year
  21. Michigan Department of Health & Human Services. Mar 14, 2018 Measles case identified in Michigan; health officials urge protection through vaccination. http://www.michigan.gov/mdhhs/0,5885,7-339--463739--,00.html - New Jersey Department of Health. Mar 14, 2018 Public Health Alert: Potential Measles Exposure at Newark Liberty International Airport. http://www.nj.gov/health/news/2018/approved/20180314z.shtml
  22. World Health Organization (WHO) Measles cases spike globally due to gaps in vaccination coverage. WHO News Release. Nov 29, 2018 http://www.who.int/news-room/detail/29-11-2018-measles-cases-spike-globally-due-to-gaps-in-vaccination-coverage - Dabbagh A, Laws RL, Steulet C, et al. Progress Toward Regional Measles Elimination - Worldwide, 2000- 2017. MMWR Morb Mortal Wkly Rep 2018;67:1323-1329 https://www.cdc.gov/mmwr/volumes/67/wr/mm6747a6.htm
  23. World Health Organization (WHO) Measles - European Region Disease outbreak news - update. 6 May 2019 https://www.who.int/csr/don/06-may-2019-measles-euro/en/
  24. Strebel PM, Orenstein WA. Measles. N Engl J Med. July 10, 2019 PMID: 31184814 https://www.nejm.org/doi/full/10.1056/NEJMcp1905181
  25. Mina MJ, Kula T, Leng Y et al Measles virus infection diminishes preexisting antibodies that offer protection from other pathogens. Science 01 Nov 2019: Vol. 366, Issue 6465, pp. 599-606 PMID: 31672891 https://science.sciencemag.org/content/366/6465/599
  26. Hubschen, JM Gouandjika-Vasilache I, Dina J Measles. Lancet. 2022 Feb 12;399(10325):678-690 PMID: 35093206 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02004-3/fulltext
  27. Mathis AD, Raines K, Masters NB et al. Measles - United States, January 1, 2020-March 28, 2024. MMWR Morb Mortal Wkly Rep 2024;73:295-300 https://www.cdc.gov/mmwr/volumes/73/wr/mm7314a1.htm
  28. Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings Updated July 2019 https://www.cdc.gov/infectioncontrol/guidelines/measles/index.html
  29. Centers for Disease Control and Prevention (CDC) Measles Cases and Outbreaks http://www.cdc.gov/measles/cases-outbreaks.html