Measles (Rubeola)

1. Measles (Rubeola)

2. Definition Koplik spots Coryza Measles is a communicable disease manifesting with fever , cough , coryza , lacrimation and koplik spots in the pre – eruptive phase and a maculopapular rash starting at 4th or 5th day of the illness. Coryza : profuse discharge from the mucous membrane of the nose koplik spot : small, white spots (often on a reddened background) that occur on the inside of the cheeks early in the course of measles.

3. Ecological triad • Agent: Measles( paramyxovirus ,RNA virus) • Age: children (6months -3 years) • Measles tend to be very serious in malnourished children, mortality is 400 times higher. Both sexes are affected • Immunity : - • one attack of measles gives immunity for life. • Infants acquire immunity transplacentally from mothers who have had measles or measles immunization. This immunity is usually completed for the first 4–6 months of life. • Reservoir : - Man is only the reservoir of infection.

4. Environment Incidence is higher in spring and winter Incidence is higher in densely populated urban areas Natural history Reservoir is a case of measles Source of infection: nasopharyngeal secretions, lacrimal secretion, urine Infectious period: 4 days before, and 5 days after the onset of rash

5. Mode of transmission Directly from person to person by droplet infection, droplet nuclei Other modes –fomites, airborne Incubation period: 8 – 12 days

6. Pathogenesis • Virus infects by invasive of respiratory tract . • After entering the viral particles infects the respiratory epithelium and local multiplication leads to primary viremia ( day 2 – 3 ) and subsequently spread to the reticuloendothelial system. • Cells of reticuloendothelial system necrose , causing secondary viremia ( day 5 – 7 ) which is responsible for systemic symptoms. • Multinucleated gaint cells can be demonstrated in both epidermis and oral epithelium by 7 – 11 days • Two types of gaint cell are seen : - • Warthin – Finkeledy cells of reticuloendothelial system • Epithelium gaint cells of respiratory tract • During infection , CD4T and CD8 cells are activated and participate in clearance of virus and development of rash. During recovery,level of interleukin 4 is elevated • IL-4: protein that stimulates the immune system to develop mast cells, resting T-cells, and activated B-cells.

7. Clinical features Prodromal : - onset is acute with moderate elevation of temperature , cough , running of nose , sneezing , redness of eyes and excessive lacrimation - on second or third day : koplik spots appear on the inner side of the cheek, opposite to the second molars . - Koplik spots increase in number for 2 to 3 days and disappear by the end of second day of the rash

8. Koplik’s spot:

9. Eruptive phase : • With the appearance of rash on the 4th day the fever tends to rise again • Early rash is erythematous and blanches on pressure ( blotchy ) • First appears behind the ears , near the hair line on the forehead , face and neck and spread to trunk , extremities , palms and soles within 3 days. • The rash now appears brownish , and does not fade on pressure. • Rash start disappearing after 4 to 5 days in the same order in which it appeared • Fever and rash lasts for about a week in uncomplicated cases • May complain anorexia , malasie , generalised lymphadenopathy

10. Maculo-papular rash:

11. Diagnosis • Clinical diagnosis: • Laboratory diagnosis: • Blood count – leucocytosis in early stages followed by increased lymphocytes • Sputum or urine culture • Serological tests Complement fixation test Haemagglutination test • Enzyme-linked immunosorbent assay (ELISA)

12. Differential diagnosis • Rubella : rash is pink , maculopapular and discrete • Infectious mononucleosis : rash is associated with generalised lymphadenopathy and hepatosplenomegaly • Meningococcemia : rash appears within 24 hours. Fever , vomiting , irritability and possibly stiff neck are present • Drug rash : H / o drugs administration • Sunburn • Roseola infantum : - faint pink maculopapular rash.

13. Treatment : • It is a self limiting disease unless it is complicated • Symptomatic and supportive • Body and oral hygiene are attended to • Parents are encouraged to give bath to the child and mouth is washed and teeth are brushed daily • Adequate amount of fluids orally • Fever (paracetamol and hydrotherapy ) • Severe cough ( saline nebulization ) • Vitamin A decrease the severity , complication rate and mortality. Dose : 2 lac units , orally children older than one year of age for 2 consecutive days.

14. Prevention and control • Control measures • Isolation • Bed rest • Supportive Tx- vit. A , • Immunization of contacts within 2 days of exposure • Preventive measures • Active immunization(9 months, 0.5cc,IM/SC,deltoid) • Passive immunization (Human gamma globuline0.25ml/kg IM within 5 days of exposure)

15. Vaccines Dose and schedule: 0.5ml – S/C – 9months Adverse reactions: Measles like illness, febrile convulsion, toxic shock syndrome, transient thrombocytopenia Contraindications: acute illness, untreated malignant diseases, immunodeficiency, pregnancy, received any live vaccine within 3 weeks

16. complications • Respiratory tract : • otitis media , cervical lymphadenopathy , laryngitis , laryngotracheitis , interstitial pneumonia ,bronchopneumonia • Encephalitis • Digestive system : • Persistent diarrhea , appendicitis ( lymphoid tissue blocking the lumen of appendix ) , hepatitis , ileocolitis Malnutrition : PEM Others : acute glomerulonephritis , disseminated intravascular coagulation .