Measles Involving Hepatitis in a Traveler to China: A Case Report and Review of the Literature

1. Measles Involving Hepatitis in a Traveler to China: A Case Report and Review of the Literature Heather Schlesinger, DO, CPT, MC Douglas M. Maurer, DO, FAAFP, MAJ, MC Madigan Army Medical Center Fort Lewis, Washington How many here have seen a case of measles? Today I like to share a case of measles involving hepatitis in a traveler to China, a brief review of the literature and the implications for family medicine physicians. How many here have seen a case of measles? Today I like to share a case of measles involving hepatitis in a traveler to China, a brief review of the literature and the implications for family medicine physicians.

2. Classic Measles Incubation period Prodrome -Cough -Coryza -Conjunctivitis -Enanthem Exanthem Acquisition of the virus occurs via respiratory mucosa and possibly the conjunctiva. The incubation period lasts 10 to 14 days during which the patient is generally asymptomatic. This is followed by a prodrome typically including fever, malaise and anorexia followed by the classic three C’s- cough, coryza, and conjunctivitis. The severity of the conjunctivitis is variable and may also be accompanied by lacrimation or photophobia. These symptoms usually last 2-3 days but may persist for as long as 8 days. Exanthem: blanching maculopapular rash beginning on the face and spreading caudally to the neck, trunk and extremities. Lesions may become confluent, especially on the face and palms and soles are rarely involved. Rash usually begins to improve within 48 hours. 3-4 days after it first appears it fades to a brownish color followed by fine desquamation. RECOVERY- cough may persist for 1-2 weeks after infection. Fever does not usually persist beyond the third day.Acquisition of the virus occurs via respiratory mucosa and possibly the conjunctiva. The incubation period lasts 10 to 14 days during which the patient is generally asymptomatic. This is followed by a prodrome typically including fever, malaise and anorexia followed by the classic three C’s- cough, coryza, and conjunctivitis. The severity of the conjunctivitis is variable and may also be accompanied by lacrimation or photophobia. These symptoms usually last 2-3 days but may persist for as long as 8 days. Exanthem: blanching maculopapular rash beginning on the face and spreading caudally to the neck, trunk and extremities. Lesions may become confluent, especially on the face and palms and soles are rarely involved. Rash usually begins to improve within 48 hours. 3-4 days after it first appears it fades to a brownish color followed by fine desquamation. RECOVERY- cough may persist for 1-2 weeks after infection. Fever does not usually persist beyond the third day.

3. Classic Measles Incubation period Prodrome -Cough -Coryza -Conjunctivitis -Enanthem Exanthem During the prodrome period, the pathognomonic enanthem known as Koplik’s splots may appear. These are 1-3 mm whitish, grayish, or bluish elevations with an erythematous base seen on the buccal mucosa usually opposite the molar teeth. These lesions do not appear in all cases and occurs approximately 48 hours before the exanthem appears. . . . Which can be seen hereDuring the prodrome period, the pathognomonic enanthem known as Koplik’s splots may appear. These are 1-3 mm whitish, grayish, or bluish elevations with an erythematous base seen on the buccal mucosa usually opposite the molar teeth. These lesions do not appear in all cases and occurs approximately 48 hours before the exanthem appears. . . . Which can be seen here

4. Classic Measles The exanthem is blanching maculopapular rash beginning on the face and spreading caudally to the neck, trunk and extremities. Lesions may become confluent, especially on the face and the palms and soles are rarely involved. The rash usually begins to improve within 48 hours and in 3-4 fades to a brownish color followed by fine desquamation. The exanthem is blanching maculopapular rash beginning on the face and spreading caudally to the neck, trunk and extremities. Lesions may become confluent, especially on the face and the palms and soles are rarely involved. The rash usually begins to improve within 48 hours and in 3-4 fades to a brownish color followed by fine desquamation.

5. Case Presentation

6. Case Presentation: History 37 yo female presented to travel clinic regarding trip to China Childhood immunizations up to date Prior to her departure, patient presented to her PCM with sinus complaints Patient given rx for amoxicillin August 2005- 37 yo female presented to travel clinic regarding trip to China to adopt a child. She reported her childhood immunizations complete and received typhoid vaccination. Prior to her departure for China she presented to her PCM with a three week history of congestion and new onset sinus pressure. She was subsequently given amoxicillin to take if sinus symptoms worsened while in China August 2005- 37 yo female presented to travel clinic regarding trip to China to adopt a child. She reported her childhood immunizations complete and received typhoid vaccination. Prior to her departure for China she presented to her PCM with a three week history of congestion and new onset sinus pressure. She was subsequently given amoxicillin to take if sinus symptoms worsened while in China

7. Case Presentation: History In China, patient developed fever, headache, and malaise Patient started her amoxicillin Two days later, she developed a rash on her chest and face and a cough Seen in ER and diagnosed with sinusitis and a drug reaction Instructed to stop the amoxicillin Prior to her departure from China the patient developed fever, headache, and malaise and began taking the previously prescribed amoxicillin Two days after starting the amoxicillin the patient developed a rash on her chest and face and a productive cough She was subsequently seen in the Emergency Room where she was diagnosed with sinusitis and a drug reaction. She was instructed to stop the antibiotic. Prior to her departure from China the patient developed fever, headache, and malaise and began taking the previously prescribed amoxicillin Two days after starting the amoxicillin the patient developed a rash on her chest and face and a productive cough She was subsequently seen in the Emergency Room where she was diagnosed with sinusitis and a drug reaction. She was instructed to stop the antibiotic.

8. Case Presentation: History Over the next two days, the rash became more confluent on her face and upper chest and spread to her trunk and arms Patient represented to ER with HA, abdominal pain, loose stools and questionable mental status changes Over the course of the next two days the patient had persistent fevers and her rash become more confluent on her face and upper chest with spread to her trunk and arms. She represented with extreme HA, abdominal pain, loose stools and as per her husband “slightly delerious”. Over the course of the next two days the patient had persistent fevers and her rash become more confluent on her face and upper chest with spread to her trunk and arms. She represented with extreme HA, abdominal pain, loose stools and as per her husband “slightly delerious”.

9. Case Presentation: Physical HEENT: Generalized facial edema and left maxillary sinus tenderness Eyes watery, conjunctiva not injected Oropharynx without erythema or lesions Abd: mild diffuse tenderness, no HSM Skin: confluent maculopapular rash on face and upper chest with additional lesions on trunk and proximal arms On exam she had generalized facial edema and left maxillary sinus tenderness. Her eyes were watery and her conjunctiva were not injected. Her oropharynx was benign, no oral lesions were noted. Abdomen soft with mild diffuse tenderness, no hepatosplenomegaly. She had an erythematous maculopapular rash confluent on her face and upper chest with additional lesions on her abdomen, back, and proximal arms On exam she had generalized facial edema and left maxillary sinus tenderness. Her eyes were watery and her conjunctiva were not injected. Her oropharynx was benign, no oral lesions were noted. Abdomen soft with mild diffuse tenderness, no hepatosplenomegaly. She had an erythematous maculopapular rash confluent on her face and upper chest with additional lesions on her abdomen, back, and proximal arms

10. The patients rash was similar to the one seen in these pictures. The patients rash was similar to the one seen in these pictures.

11. Case Presentation: Work-up CT head: sinusitis Lumbar Puncture: normal CBC: WBC 3.6 with 43 bands LFT: AST 528, ALT 490, GGT 295 Admitted for further work-up Her work-up in the ED included a CT of the head demonstrating sinusitis, lumbar puncture was normal, CBC with no elevation in her white count but bandemia and transaminitis. She was admitted for further work-up and supportive care.Her work-up in the ED included a CT of the head demonstrating sinusitis, lumbar puncture was normal, CBC with no elevation in her white count but bandemia and transaminitis. She was admitted for further work-up and supportive care.

12. Case Presentation: Course Liver enzymes down trended Hepatitis, EBV / CMV serologies, stool studies negative Patient discharged on day 5 Final diagnosis: viral exanthem vs. drug reaction, hepatitis and sinusitis During her hospitalization her liver enzymes down trended. Hepatitis, EBV / CMV serologies, and stool studies were all negative. The patient was discharged on day 5 feeling markedly improved. ID and dermatology were both consulted during hospitalization and the final diagnosis on discharge was viral exanthem versus drug reaction, hepatitis and sinusitis.During her hospitalization her liver enzymes down trended. Hepatitis, EBV / CMV serologies, and stool studies were all negative. The patient was discharged on day 5 feeling markedly improved. ID and dermatology were both consulted during hospitalization and the final diagnosis on discharge was viral exanthem versus drug reaction, hepatitis and sinusitis.

13. Case Presentation: Follow-up Several days later, a member of the travel group was diagnosed with measles Serology was performed and confirmed measles in this patient In total, three of the adults from the travel group were diagnosed with measles Several days following discharge of this patient a member of the travel group was diagnosed with measles. At this time the CDC began an investigation of contacts to include calling members of the travel group. 2 other members of the travel group, including the patient in this case report were identified to have had illness involving rashes. Subsequently the providers from this case were contacted by the CDC with the recommendation to test was measles. Serology was performed confirming the diagnosis. In total, three of the adults from the travel group were diagnosed with measles.Several days following discharge of this patient a member of the travel group was diagnosed with measles. At this time the CDC began an investigation of contacts to include calling members of the travel group. 2 other members of the travel group, including the patient in this case report were identified to have had illness involving rashes. Subsequently the providers from this case were contacted by the CDC with the recommendation to test was measles. Serology was performed confirming the diagnosis. In total, three of the adults from the travel group were diagnosed with measles.

14. Discussion So what are some key points that we as family physicians need to be aware of.So what are some key points that we as family physicians need to be aware of.

15. Measles and the Traveler Measles vaccine was introduced in 1963 Incidence decreased by 99% in US Average 80 measles cases annually in the US from 1999-2003 30 million cases annually worldwide resulting in 454,000 deaths Measles vaccine was introduced in 1963 and incidence has decreased by 99% in the United States. From 1999-2003 there were an average of 80 cases annually in the United States. However, worldwide there are 30 million cases anually resulting in 454,000 deaths.Measles vaccine was introduced in 1963 and incidence has decreased by 99% in the United States. From 1999-2003 there were an average of 80 cases annually in the United States. However, worldwide there are 30 million cases anually resulting in 454,000 deaths.

16. On this map color indicates incidence of measles and immunizations. Not surprisingly Africahas both a lower rate of immunization and a higher incidence rate. As you can see on the map there is no data regarding vaccination in China and there incidence is reported to be comparable to the United States. However, as with many diseases, reporting practices have been questionable.On this map color indicates incidence of measles and immunizations. Not surprisingly Africahas both a lower rate of immunization and a higher incidence rate. As you can see on the map there is no data regarding vaccination in China and there incidence is reported to be comparable to the United States. However, as with many diseases, reporting practices have been questionable.

17. Measles and the Traveler Travelers should ensure immunity Immune if: Documentation of physician diagnosed measles Laboratory evidence of measles immunity Proof of receipt of two doses of live measles vaccine **Individuals born before 1957 are not considered susceptible as most of these individuals have had measles Based on the high prevalence worldwide travelers should ensure immunity. One is considered immune if they have: Documentation of physician diagnosed measles Laboratory evidence of measles immunity Proof of receipt of two doses of live measles vaccine The first dose should have been on or after the first birthday and the second dose at least 28 days later **Individuals born before 1957 are generally not considered susceptible as most of these individuals have had measles Further review of this patient’s history show documentation in her baby book of receiving vaccination at age one. Had this been known at the time of presentation to the travel clinic perhaps she would have warrented titers and possibly reimmunization.Based on the high prevalence worldwide travelers should ensure immunity. One is considered immune if they have: Documentation of physician diagnosed measles Laboratory evidence of measles immunity Proof of receipt of two doses of live measles vaccine The first dose should have been on or after the first birthday and the second dose at least 28 days later **Individuals born before 1957 are generally not considered susceptible as most of these individuals have had measles Further review of this patient’s history show documentation in her baby book of receiving vaccination at age one. Had this been known at the time of presentation to the travel clinic perhaps she would have warrented titers and possibly reimmunization.

18. International Adoption Trends 1990 - 2006 For the past six years China has been the number one country for adoptees coming to the United States. During 1998--2005, annual U.S. adoptions of children from China increased by 88%. As can be seen here dating back to 1990 adoption rates have been steadily increasing. One might assume that with ever increasing media coverage of International Adoption this trend will continue.For the past six years China has been the number one country for adoptees coming to the United States. During 1998--2005, annual U.S. adoptions of children from China increased by 88%. As can be seen here dating back to 1990 adoption rates have been steadily increasing. One might assume that with ever increasing media coverage of International Adoption this trend will continue.

19. Hepatitis and Measles Hepatitis noted to be a complication of measles in the 1960’s In adults, elevations in liver enzymes occurs in 56-82% of measles cases In children, occurs in 4-31% Liver involvement more common with more severe cases of measles Hepatitis was noted to be a complication of measles in 1960’s. Although rarely mentioned, studies have shown that elevations in liver enzymes occur in 56-82% of adults with measles and 4-31% of children. Liver involvement was observed to be more common in those with more severe cases of measles. Hepatitis was noted to be a complication of measles in 1960’s. Although rarely mentioned, studies have shown that elevations in liver enzymes occur in 56-82% of adults with measles and 4-31% of children. Liver involvement was observed to be more common in those with more severe cases of measles.

20. Conclusion Measles remains prevalent worldwide Documentation of immunity should be provided before traveling International adoption is steadily increasing Hepatitis is a common complication Family physicians must be alert to the possibility of measles in international travelers and the differential of hepatitis In conclusion, although rare in the United States measles remains prevalent worldwide. Documentation of immunity should be provided before traveling. Over the past 20 years international adoption is steadily increasing, in turn increasing the chance of exposure to measles. Hepatitis is a rarely thought of but in fact common complication of measles. Family physicians must be alert to the possibility of measles in international travelers and in the differential of hepatitis.In conclusion, although rare in the United States measles remains prevalent worldwide. Documentation of immunity should be provided before traveling. Over the past 20 years international adoption is steadily increasing, in turn increasing the chance of exposure to measles. Hepatitis is a rarely thought of but in fact common complication of measles. Family physicians must be alert to the possibility of measles in international travelers and in the differential of hepatitis.

21. Comments? Thank you! Thank you, at this time are there any questions or comments.Thank you, at this time are there any questions or comments.

22. From "Polka-Dot Puss" (1949)

23. References Mandell, Gerald L., MD, MACP, John E. Bennett, MD and Raphael Dolin, MD. Principles and Practice of Infectious Diseases. 6th Edition. Philadelphia: Churchill Livingstone, 2005. Clinical presentation and diagnosis of measles. UpToDate online. (Accessed March 9, 2007 at http://www.utdol.com/utd/content/topic.do?topicKey=viral_in/8667&type=A&selectedTitle=1~38). PowerPoint Presentation: Acute Measles Infection in Adults Following Travel to China—2006. Thomas M. Weiser, MD, MPH, Missouri Department of Health and Senior Services State Branch, CDD, OWCD. Measles Among Adults Associated with Adoption of Children in China --- California, Missouri, and Washington, July--August 2006. MMWR. February 23, 2007 / 56(07);144-146. Fact Sheet Number 286: Measles. Revised March 2006. World Health Organization. (Accessed January 3, 2007 at http://www.who.int/mediacentre/factsheets/fs286/en/.). Papania, Mark. Health Information for International Travel, 2005-2006. U.S. Department of Health and Human Services, Public Health Service. 2005. International Adoption. US Department of State (Accessed March 9, 2007 at http://trave.state.gov/family/adoption/stats/stats_451.html). Nickell, Michael D., Preston B. Cannady, Jr., Gregory A. Schwitzer. Subclinical Hepatitis in Rubeola Infections in Young Adults. Ann Intern Med 1979;90:354-355.

24. References, cont. Gavish, Dov, Yosef Keinman, Abraham Morag, Tova Chajek-Shaul. Hepatitis and Jaundice Associated With Measles in Young Adults. Arch Intern Med 1983;143:674-677. Shalev-Zimels, Hanna, Zvi Weizman, Chaim Lotan, Dov Gavish, Zvi Ackerman, and Abraham Morag. Extent of Measles Hepatitis in Various Ages. Hepatology 1988;8:138-1139. Papadopoulou, AL, M Theordoridou, V Syriopoulou, G Mostrou and CH Kattamis. Hepatitis in Children Hospitalized With Measles: The Experience Acquired After a Greek Epidemic. Journal of Paediatrics and Child Health 2001;37:55. Photos: Tom and Jerry: http://en.wikipedia.org/wiki/Image:Tomandjerrywithmeasles.JPG. Accessed March 9, 2007. Brad Pitt, Angelina Jolie and Family: www.msnbc.msn.com/id/17499011/. Accessed March 9, 2007. Madonna and son: http://photos.ivillage.com/entertainment/starsnapshots/MADONNA_BABY_300.jpg. Accessed March 9, 2007.