5th Annual Advocacy Project:

ImmuneWiseSection on Medical Students, Residents,

and Fellowship Trainees2009-2010

Morning Report

Case Presentation

• 4 year old female is on the illness clinic schedule

• Her mom reports 2 days of fever and decreased energy level

Case Presentation

• Review of Systems– Temp to 102°F– Mild headache– Eye redness– Mild congestion– Non-productive cough– No GI complaints– No rash

• PMHx– Healthy– Due for 4-5 year old

immunizations

• SHx– Lives with parents– No known sick

contacts– Recent travel to

Disney World (about 10 days ago)

Case Presentation - Exam

• General: Cooperative, NAD but appears ill• HEENT: PERRL, bilateral conjunctival erythema

and watery eyes, nares patent, MMM without lesions, neck supple, no lymphadenopathy

• Chest: CTA bilaterally, no wheeze/rales/rhonchi; HRRR, no murmur/rub/gallop

• Abd: Active BS, soft, non-tender, no HSM• Skin: No rash or lesions noted

Case Presentation

• Diagnosed with a viral upper respiratory infection

• Supportive care was discussed with the patient’s mother

Case Presentation

• The 4 year old returns the next day with a new rash…

• Exam is unchanged except for a blotchy, blanching erythematous maculopapular rash on her face and neck

Differential Diagnosis

- Discussion

Management

MeaslesEpidemiology

• Humans are the only natural host• Transmitted by direct contact with droplets

– may contract from airborne droplets too

• Most common in preschool and early school-aged children with a late winter peak

• Vaccine licensed in 1963• Vaccine failure rate of 5% in those with only a

single dose

MeaslesEpidemiology

Measles Epidemiology

Measles Clinical Presentation

• Incubation period of 8-12 days• Symptoms and signs include:

– Fever, malaise, cough– Conjunctivitis, coryza, +/- photophobia– Koplik spots on soft palate (often occur before

the rash and are diagnostic)– Rash, usually day 2-3 of illness

• Contagious for 1-2 days before onset of symptoms until ~4 days after rash appears

Measles Clinical Presentation

Measles Diagnosis

• Serum sample positive for measles IgM antibody on initial presentation– Sensitivity varies - low in first 72 hours of rash– If the initial test is negative, consider repeating

after the rash is present > 72 hours

• Significant rise in measles IgG in paired acute – convalescent samples

• Measles RNA in blood, throat, nasopharyngeal or urine samples (by PCR)

MeaslesComplications

• Complications include:– Otitis media– Croup or bronchopneumonia– Diarrhea

• Severe complications:– Acute encephalitis in 1/1000 cases– Death in 1-3/1000 cases

• Usually due to respiratory or neuro complications

– Subacute sclerosing panencephalitis (SSPE)• Degenerative CNS disease

Measles Treatment

• Supportive care

• Vitamin A– Give if vitamin A deficiency is endemic– Give in the U.S under certain conditions

Consult Red Book

• Ribavirin– Not FDA approved, but may help those

severely affected and immunocompromised

Measles Infection Control

• Vaccine given within 72 hrs of exposure my provide protection in susceptible individuals

• Immune globulin given within 6 days of exposure may prevent or modify measles