AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

Background

Measles (rubeola) is a highly contagious and potentially serious viral infection, with a characteristic viral prodrome and rash. It was once one of the most common and important infections worldwide, but it has become very rare in developed countries where vaccine use is prevalent. Unfortunately, it is the leading vaccine-preventable cause of child mortality worldwide.

Pathophysiology

Measles is caused by a single-stranded RNA paramyxovirus, which is transmitted by respiratory droplets produced by sneezing and coughing. Humans are the only known reservoir for this viral infection.

The portal of entry for the virus is the respiratory tract and possibly the conjunctivae. After undergoing local replication and spreading to regional lymph nodes, viremia ensues, which results in viral dissemination throughout the body, particularly to the skin and mucous membranes. This results in the characteristic clinical features of the infection.

Frequency

United States

Since 1994, most cases of measles have been imported or importation associated, suggesting that measles is no longer an indigenous disease. In 2005, 66 cases of measles were reported to the Centers for Disease Control and Prevention (CDC).¹ Of these, 34 were linked with a single outbreak in Indiana associated with the return of an unvaccinated 17-year-old American traveling in Romania.

International

In developing countries, measles affects 30 million children a year and causes 1 million deaths. Measles causes 15,000-60,000 cases of blindness per year.

Mortality/Morbidity

Although measles is a clinically significant viral illness, it is usually benign and uncomplicated. Complications most commonly occur in adults and in children who are undernourished, who have vitamin A deficiency, who have an intense exposure to measles or no previous vaccination, or who are immunocompromised.

Most complications occur because the measles virus suppresses the host's immune responses, resulting in a reactivation of latent infections or superinfection by a bacterial pathogen. Therefore, pneumonia, either due to the measles virus itself, tuberculosis, or another bacterial etiology, is the most frequent complication.

Croup, encephalitis, and pneumonia are the most common causes of death associated with measles.

• The measles virus frequently involves the CNS directly; however, clinically apparent encephalomyelitis occurs in about 1 of every 1000-2000 patients with measles. This condition is fatal in about 10% of patients.
• In children with lymphoid malignant diseases, delayed-acute measles encephalitis may develop 1-6 months after the acute infection and is generally fatal. Even rarer is subacute sclerosing panencephalitis (SSPE), a disease with a latent period of several years in children who had measles when they were younger than 2 years.
• Other complications are otitis media, thrombocytopenia with purpura and bleeding, myocarditis, hepatitis, pericarditis, and severe keratitis that may progress to blindness.

Sex

No sex predilection is known.

Age

• Of the 66 cases reported in the United States in 2005, 7 (10.6%) involved infants, 4 (6.1%) involved children aged 1-4 years, 33 (50%) involved persons aged 5-19 years, 7 (10.6%) involved adults aged 20-34 years, and 15 (22.7%) involved adults older than 35 years.¹
• Measles in heavily populated, underdeveloped countries is most common in children younger than 2 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

History

• Approximately 10 days after the initial exposure to the virus, the classic viral prodrome occurs.
• • Fever
  • Nonproductive cough
  • Coryza
  • Conjunctivitis
  • Additional prodromal symptoms may include malaise, myalgias, photophobia, and periorbital edema.
• Within 2-3 days, the pathognomonic Koplik spots typically arise on the buccal, gingival, and labial mucosae.
• A rash is present.
• • It typically begins at the hairline and spreads caudally over the next 3 days as the prodromal symptoms resolve.
  • The rash lasts 4-6 days and then fades from the head downward.
  • Desquamation may be present but is generally not severe.
  • Complete recovery from the illness generally occurs within 7-10 days from the onset of the rash.
• Modified measles occurs in children who have received serum immunoglobulin after their exposure to measles. The measles symptom complex may still occur, but the incubation period is as long as 21 days, with the same symptoms as measles but milder.
• Atypical measles occurs in individuals who were previously immunized with the killed measles vaccine between 1963 and 1967 and who have incomplete immunity.
• • When they are exposed to the measles virus, a mild or nonexistent prodrome of fever, headache, abdominal pain, and myalgias precedes a rash that begins on the hands and feet and spreads centrally.
  • The rash is most prominent in the body creases and may be macular, hemorrhagic vesicles, petechial, or urticarial.
  • Complications may include pneumonia, pleural effusion, hilar lymphadenopathy, hepatosplenomegaly, hyperesthesia, or paresthesia.
  • All persons vaccinated after 1967 received the live attenuated measles vaccine, which is not associated with atypical measles.

Physical

• Patients tend to appear moderately ill and uncomfortable because of their viral prodromal symptoms.
• The Koplik spots are 1-2 mm, blue-gray macules on an erythematous base.
• The measles rash is a maculopapular erythematous rash that involves the palms and soles.
• Lesion density is greatest above the shoulders, where macular lesions may coalesce.

Causes

The cause is a single-stranded RNA paramyxovirus.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory investigation is generally unnecessary, given the classic clinical presentation.
• Findings on serology (measles CF or HI antibody studies) or viral culture can confirm the diagnosis, but this is unnecessary in routine cases.
• During the prodrome and rash stages, the absolute lymphocyte count may be low.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

Emergency Department Care

Supportive care is normally all that is required.

• Occasionally, intravenous (IV) hydration is required, as patients may be markedly febrile, and they may become dehydrated.
• Fever management with standard antipyretics is appropriate.
• Secondary infections, such as pneumonia and otitis media, should be treated with antibiotics.
• Postexposure prophylaxis may be given within 6 days of exposure with immune globulin for high-risk patients, such as immunocompromised children and pregnant women.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

Drug Category: Vitamins

Vitamin A treatment for children with measles in developing countries has been associated with a marked reduction in morbidity and mortality. The World Health Organization recommends vitamin A administration to all children with measles in communities where vitamin A deficiency is a recognized problem and where the MV-related mortality rate exceeds 1%. Of note, low serum concentrations of vitamin A are found in children with severe measles in the United States. Thus, consider supplemental vitamin A in patients aged 6 months to 2 years who are hospitalized with measles and its complications (eg, croup, pneumonia, diarrhea).

Also recommend vitamin A supplementation for children who have any of the following criteria:

• Immunodeficiency
• Clinical evidence of vitamin A deficiency (eg, ophthalmologic complications)
• Moderate-to-severe malnutrition, including eating disorders 
• Impaired intestinal absorption
• Recently emigrated from an area with high mortality rates due to measles

Drug Category: Vaccines

Measles-mumps-rubella (MMR) vaccine is available in the United as an attenuated live-virus vaccine. For information regarding vaccines and immunization schedules, see the CDC Web site.²

Claims that suggest an association between measles vaccine and pervasive developmental or other neurologic disorders have not been substantiated. Vaccines are used for universal immunization of children older than 12 months in the United States or in children at age 9 months in developing countries with high endemicity. In the United States, a second dose can be administered as soon as 2 months later but is generally administered at age 4-6 years. All adults born after 1957 should receive a second dose of MMR unless they are documented as seropositive for measles IgG antibody by enzyme immunoassay (EIA).

If administered within 72 hours of exposure to measles-naive individuals, MMR may prevent or attenuate disease. (In a susceptible household contact, consider immunoglobulin instead.)

In the United States, 48 states and the District of Columbia require a second dose of measles vaccine for school enrollment. Rates of seroconversion average 85% after a single dose at age 9 months (the recommended strategy for routine immunization in developing countries), 95% after a single dose at 12 months, 98% after a single dose at age 15 months, and greater than 99% after 2 doses administered after age 12 months.

The American Academy of Pediatrics Red Book³ suggests an interval of at least 5-6 months after immune globulin IM is administered before administration measles vaccine.

Drug Category: Immunoglobulins

Human immunoglobulin prevents or modifies measles in susceptible individuals if administered within 6 days of exposure. 

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients generally do not require admission, though some may become notably dehydrated because of insensible losses from fever.
• Patients with severe complicating infections, such as pneumonia or encephalomyelitis, should be admitted for observation and antibiotics, as appropriate to their clinical condition.

Further Outpatient Care

• Patients should receive follow-up care with their primary care physician for surveillance of complications arising from the illness.

Complications

• Subacute sclerosing panencephalitis
• Otitis media
• Thrombocytopenia with purpura and bleeding
• Myocarditis
• Pericarditis
• Hepatitis
• Severe keratitis, which may progress to blindness

Prognosis

• The prognosis is excellent, with full recovery without scarring in patients without complications.
• Measles encephalitis has a 10% mortality rate.

Patient Education

• For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Measles and Skin Rashes in Children.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

Special Concerns

• Immunocompromised children and adults are at increased risk for severe infections and superinfections and have an increased mortality and morbidity rate.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• MEDICATION
• Follow-up
• Miscellaneous
• References

1. MMWR. Morbidity & Mortality Weekly Report. Centers for Desease Control and Prevention. Measles--United States, 2005. MMWR Morb Mortal Wkly Rep. Dec 22 2006;55(50):1348-51. [Medline]. [Full Text].
2. Immunization Schedules. Centers for Disease Control and Prevention (CDC). Available at http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed December 18, 2007.
3. Committee on Infectious Diseases, American Academy of Pediatrics. Measles. In: Pickering LK, ed. Red Book: Report of the Committee on Infectious Disease. 27. Elk Grove, Il: American Academy of Pediatrics; 2006:441-452.
4. Anonymous. Cutaneous viral diseases. Sci Am Med. 1989: 1-2.
5. Cherry JD. Measles virus. In: Textbook of Pediatric Infectious Diseases. 5^th ed. 2004:2283-99.
6. Mercurio MG, Elewski BE. Cutaneous manifestations of systemic viral, bacterial, and fungal infections and protozoal disease. In: Dermatologic Signs of Internal Disease. 2^nd ed. 1995:253-4.
7. MMWR. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. Measles--United States, 1996, and the interruption of indigenous transmission. MMWR Morb Mortal Wkly Rep. Mar 21 1997;46(11):242-6. [Medline]. [Full Text].
8. MMWR. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. Status report on the Childhood Immunization Initiative: reported cases of selected vaccine-preventable diseases--United States, 1996. MMWR Morb Mortal Wkly Rep. Jul 25 1997;46(29):665-71. [Medline]. [Full Text].
9. Moss WJ, Ota MO, Griffin DE. Measles: immune suppression and immune responses. Int J Biochem Cell Biol. Aug 2004;36(8):1380-5. [Medline].
10. Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis. May 1 2004;189 Suppl 1:S4-16. [Medline].
11. Semba RD, Bloem MW. Measles blindness. Surv Ophthalmol. Mar-Apr 2004;49(2):243-55. [Medline].

Article Last Updated: Dec 20, 2007