TASHKENT MEDICAL ACADEMY Department of infectious diseases and children infectious diseases

1. TASHKENT MEDICAL ACADEMYDepartment of infectious diseases and children infectious diseases “Measles. Scarlet fever. Rubella.” Lecturer: Candidate of Medical Science, associate professor, Кarimova М.Т.

2. MEASLES (RUBEOLA, MORBILLE) An acute, highly contagious paramixovirus infection, rubeola may be one of the most common and the most serious of all communicable childhood diseases.

3. HISTORY OF MEASLES The history of rubeola has three period: • Till using antibiotics; • The period when was used antibiotics; • The period when was started use of the measles vaccine.

4. ETIOLOGY • Agent - VIRUS - Рolyinosamorbiliorum, keep single chain RNA. Virus has complicated antigenic structure; • Virus has stable antigenic structure, against this antigen produced specific antibodies in diseased organism; • Virus unstable in the environment, sensitive for ultraviolet and direct sunlight; • Inconvertible to antibiotics; • Virus affects lymphoid tissue, reticuloendothelial system, epithelial cells of mucous membrane of respiratory tract and nervous system.

6. EPIDEMIOLOGY • Source of infection is sick person; • Virus is transmitted by air – droplet way (transmission of virus occurs through of a respiratory droplet from an infected person) • Вирусможетбытьвыделенизкрови и носоглоточныхсмывов в катаральномпериоде и в первыеднивысыпания , чтоопределяетзаразныйпериодболезни. • Susceptibility to measles is general; • Index of contagious is 0,95;

7. Pathogenesis and pathology measles virus ↓respiratory tract epithelial cells(multiply) ↓lymphoid tissue blood (first virusemia) ↓ MPS(multiply) ↓ blood (second virusemia) ↓ general toxic symptoms

8. PATHOGENESIS • Measles is a common generalized process with the electoral defeat of the central nervous system, respiratory system. • Atrium - the upper respiratory tract mucous membranes. • The pathogenesis consists of 5 phases: • 1 - phase of infection and the virus will adapt to the lymphoid tissue proliferation in regional lymph nodes. • 2 - phase the virus in the blood (primary viremia) and generalized lesions of lymphocyte system. • 3 - secondary phase of virusemia, and allergic reactions • Under the influence of immune cells and antibodies specific cytolysis of virus-containing cells occurs. The released virus being introduced into nearby epithelial cells, striking them again • 4 - Parallel phase in the body develops an allergic process that leads to sensitization of tissue. This dramatically damaged vessel walls, increasing their permeability, edema and exudation, particularly expressed in the tissues of the upper respiratory tract, causing inflammation catarrhal-necrotic • 5 phase formation of persistent immunity - in the blood concentration of specific antibodies and the virus is neutralized

9. Pathogenesis(2) • Each element of the rash - it is the focus of inflammation around the vessel, alopecia, infiltrative nature. As a result, the spread of a rash on the malpighian and granular layer of the skin there are pockets of destruction, which leads to the appearance of flaking on the site of abundant precipitation. • Bielski, Spots Filatov-Koplik - a superficial necrosis of the epithelium of the oral mucosa. • Stages of the rash in measles is associated with the highest concentration of virus infection at the gate, with an abundance of blood vessels in that area that causes a rash, first on the face, mucous membranes of the mouth, then on the trunk and then on the limbs. • In the period of eruption virus affects the nervous, endocrine system, manifested an increase intoxication. Functional impairment of the nervous system, in turn, improves adrenal function, generate a large amount of blood corticosteroids, immunosuppressive effect of rendering (measles anergy)

10. Classification of measles 1. Typical forms – by severity of illness: • Slight (easy, minor) form; • Intermediate form; • Permanent form. 2. Atypical forms: • obliterated (abortive) form; • Митигированнаякорь • Hyper toxic, hemorrhagic form (occurs very seldom) • Measles on adults.

11. CLINIC FINDINGS • Incubation is from 8 to 10 days, may be longer or shorter; • Catarrhal or prodromal phase is from 3 to 4 days, may become longer till 5-7 days; • Phase of eruption lasts 3-4 days; • And last phase is phase of pigmentation, it lasts 1-2 weeks.

12. CLINICAL MANIFESTATIONS • Typical type • 1.Incubation period is approximately 6~18days,10days is the most common. (3-4weeks) • 2 .prodromal phase 3~4 days. 2 .1 Fever; 2 .2 Catarrhal inflammation of URT; 2 .3 Koplik’s spots; 2 .4 Transient prodromal rashes.

13. 3. Eruption stage 3 .1. Time: the3~5 days after fever;but the 4th day is most common; 3 .2 . Shape:maculopapular 3.3. Seuence:behind the ear→along the hairline→face→neck→chest→back→abdomen→limbs→hand and feet(palm,sole) 3 .4 . The temperature rise continously and companied with the toxic symptoms exaggerate • 4 . Convalescent stage brown staining. fine branny desquamation. course:10-14 days

14. Atypical measles 1 . mild measles; 2 . severe measles (toxic and shock type measles); 3. hemorrhagic measles; 4 . variant measles.

15. Prodromal period • Symptoms begin to appear about 10 to 12 days after exposure to the virus, with fever followed by cough, rhino rhea and conjunctivitis. • Onset of the disease characterized by an increase in temperature to 38 ° C, the appearance of the catarrhal symptoms, and conjunctivitis. Catarrhal phenomena progressed, heavy nasal discharge, mucous, muco-purulent. The voice becomes hoarse. • Cough - dry haunting, sometimes early in the disease syndrome of croup. There is photophobia, tearing, redness konyunktiv, eyelid edema, scleral vessels Injection. • Symptom is diarrhea Patognomonichnm oral mucosa, gums. • Spots appear Bielski-Filatov-Koplik-nis on the mucosa, in front of the molars grayish-white dots, surrounded by a rim of hyperemia. • On soft and hard palate appears measles enanthema-tiny pinkish-red spots.

16. This patient presented on the third pre-eruptive day with “Koplik spots” indicative of the beginning onset of measles.

17. The rash characteristic of the period • The period begins with a rash 4-5 days of illness and is characterized by the appearance of a maculo-papular rash. The first elements of the rash appearing behind the ears, on the back of the nose, forehead in the form of small pink spots, which are increasing rapidly, merging with each other, are irregular in shape. At 2-day rash completely covers the entire body and upper arms, on a 3-day rash spreads to the extremities, hands and feet. • Stages of a characteristic feature of measles rash. • Temperature during this period is high, the catarrhal symptoms are worse. • The general condition of patients with severe, there is anxiety, delirium, drowsiness, can be nasal blooding. • Characteristic form of patient-face was puffy, pasty eyelids, nose and lips are swollen, red eyes, profuse nasal discharge.

18. PERIOD PIGMENTATION • Period of pigmentation have 6-7 days of illness. • Measles rash begins to darken, grow brown, takes brown. Pigmentation begins in the same manner as the rash appears. Maybe defurfuration • The temperature drops to normal lytic figures. • Catarrhal symptoms diminish and disappear. • Overall condition is slowly recovering. • In the period of pigmentation for a long time is the state of fatigue and anergy.

19. MITIGIROVANNAYA MEASLES • It may have received immunoglobulin, blood products, vaccine recipients. • Characterized by lengthening the incubation period to 21 days. • Shortening the catarrhal period of up to 1 day with mild catarrhal symptoms, absence of spots and enantemyBelsky - Filatov. • Period is shortened rash to 1-2 days, the rash is soft, fine in violation of the phasing of the rash. • Pigmentation of short, pale.

20. FEATURES MEASLES IN ADULTS • Has a high specific gravity. • Proceeds with a predominance of severe and moderate forms of the disease. • Severe toxicity: fever, headache, dizziness, fainting, vomiting, nosebleeds, loss of consciousness. • Pronounced cough and conjunctivitis. • Period extended until the rash 4-5 days, the rash is large, bright, exuberant. • Complicationsarerare.

21. Typical rush in patient with measles

22. Type of temperature curve

23. Condition of mucous membranes of mouth and eyes

24. Measles enanthema

25. Appearance of patient with measles

26. Typical rush

27. COMPLICATIONS • Caused by the measles virus - primary and secondary (caused mainly by bacterial infection). • The timing of development - early (refer to periods - catarrhal and rash) later (occurring in a period of pigmentation. • The respiratory system: pneumonia, laryngitis, bronchitis, pleurisy. • From the digestive system: stomatitis, enteritis, colitis. • The nervous system: meningitis, encephalitis, psychosis. • For part of the vision: conjunctivitis, blepharitis, keratitis. • On the part of the ear: otitis, mastoiditis. • With the Skin: pyoderma, cellulites

28. COMPLICATIONS • 1 .Bronchopneumonia; • 2 .Myocarditis; • 3 .Laryngitis; • 4 .Neurologic complications: Encephalitis and SSPE . 0.1-0.2% 1-4/m 2-6days 2-17ys viral encephalitis retrograde change early-viral mutation late crossed immune

29. DIAGNOSIS • 1 .Epidemiologic data; • 2 .Clinical manifestations; • 3. Laboratory findings: • 3 .1 .Multinucleated giant cells are detected in nasopharyax mucosa secretions; • 3 .2 .Measles virus can be isolated in tissues culture; • 3 .3 . Antibody titer; • 3 .4 . WBC is relative low .

30. LABORATORY FINDINGS • Blood routine • Serum Ab measurement complement combining antibody; hemagglutinin inhibiting antibody; neutralizing antibody; specific antibody IgM. • Other Ag and multinucleated giant cells • The separation of virus

31. DIFFERENTIAL DIAGNOSIS • In catarrhal period with acute viral respiratory infections; • In rush period: • rubella; • scarlet fever; • pseudo tuberculosis; • meningococcemia; • allergic exanthema (drug rashes).

32. Scarlet fever

33. Scarlet fever is a disease caused by exotoxin released by Streptococcus pyogenes. • Once a major cause of death, it is now effectively treated with antibiotics. • The term scarlatina may be used interchangeably with scarlet fever, though it is commonly used to indicate the less acute form of scarlet fever that is often seen since the beginning of the twentieth century.

34. Agent – B hemolytic streptococcus; • Source of infection is sick person; • Transmission of infection – aerosol mechanism, contact and from third person; • Index of contagious is 0,40; • Immunity – stable antitoxic immunity.

35. Pathogenesis • At the entry of infection develops inflammation; • In pathogenesis of scarlatina are played three components: • 1 – allergic component; • 2 – toxic component; • 3 – septic component.

36. Signs and symptoms

37. Incubation period is 2-7 days. • Sickness begins acute, with high temperature, vomiting, pain in the chest. • After few hours appears rush on the body. • Early in the infection, the tongue may have a whitish or yellowish coating. After 3-4 days coating is disappear and tong becomes bright red. • The tonsils and back of the throat may be covered with a whitish coating, or appear red, swollen, and dotted with whitish or yellowish specks of pus.

38. The rash is the most striking sign of scarlet fever. • It usually begins looking like a bad sunburn with tiny bumps, and it may itch. • The rash usually appears first on the neck and face, often leaving a clear unaffected area around the mouth (Philatovs’ symptom). • It spreads to the chest and back, then to the rest of the body. In body creases, especially around the underarms and elbows, the rash forms classic red streaks (on very dark skin, the streaks may appear darker than the rest of the skin). • Areas of rash usually turn white (or paler brown, with dark complected skin) when pressed on. • By the sixth day of the infection, the rash usually fades, but the affected skin may begin to peel.

39. Usually there are other symptoms that help to confirm a diagnosis of scarlet fever, including a reddened sore throat, a fever at or above 38.3 °C, and swollen glands in the neck. • Scarlet fever can also occur with a low fever. • Also, an infected person may have chills, body aches, nausea, vomiting, and loss of appetite. • When scarlet fever occurs because of a throat infection, the fever typically stops within 3 to 5 days, and the sore throat passes soon afterward. • The scarlet fever rash usually fades on the sixth day after sore throat symptoms started, and begins to peel (as above). • The infection itself is usually cured with a 10-day course of antibiotics, but it may take a few weeks for tonsils and swollen glands to return to normal.

40. Appearance of patient with scarlet fever and characteristic pharynx

41. Characteristic rush

42. Location of rush

43. Stable white dermographism peeling

44. Characteristic tonge

45. RUBELLA

46. Rubella, commonly known as German measles, is a disease caused by the rubella virus. • The name "rubella" is derived from the Latin, meaning little red. • Rubella is also known as German measles because the disease was first described by German physicians in the mid-eighteenth century. • The disease can last one to three days. • Children recover more quickly than adults.

47. Rubella virus is the pathogenic agent of the disease RUBELLA, and is the cause of congenital rubella syndrome when infection occurs during the first weeks of pregnancy. Humans are the only known host of this virus. • Rubella virus is the only member of the genus of Rubivirus and belongs to the family of Togaviridae, whose members commonly have a genome of single-stranded RNA of positive polarity which is enclosed by an icosahedralcapsid.

48. Acquired rubella • Incubation period of 14–21 days; • The primary symptom of rubella virus infection is the appearance of a rash (exanthema) on the face which spreads to the trunk and limbs and usually fades after three days; • The facial rash usually clears as it spreads to other parts of the body. • Other symptoms include low grade fever, swollen glands (sub occipital & posterior cervical lymphadenopathy), joint pains, headache and conjunctivitis; • The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38oC. • The rash of German measles is typically pink or light red. The rash causes itching and often lasts for about three days. • The rash disappears after a few days with no staining or peeling of the skin.

49. Appearance of patient with acquired rubella

50. Congenital rubella syndrome • Rubella can cause congenital rubella syndrome (CRS) in the newly born. • The syndrome (CRS) follows intrauterine infection by Rubella virus and comprises cardiac, cerebral, ophthalmic and auditory defects. • It may also cause prematurity, low birth weight, and neonatal thrombocytopenia, anemia and hepatitis. • The risk of major defects or organogenesis is highest for infection in the first trimester. • CRS is the main reason a vaccine for rubella was developed. • Many mothers who contract rubella within the first critical trimester either have a miscarriage or a still born baby. • If the baby survives the infection, it can be born with severe heart disorders, blindness, deafness, or other life threatening organ disorders. • The skin manifestations are called "blueberry muffin lesions".