Contents

IDENTITY............................................................................................................................................2
PHYSICAL EXAMINATION (December 1th 2014)..............................................................................6
General Status....................................................................................................................................6
Antropometry Status..........................................................................................................................8
Head to Toe Examination...................................................................................................................9
Neurological Examination...............................................................................................................10
Meningeal Sign............................................................................................................................10
Motoric Examination...................................................................................................................10
Autonom Examination.................................................................................................................11
Laboratory Investigation..............................................................................................................11
FOLLOW UP..................................................................................................................................13
LITERATURE REVIEW.....................................................................................................................18
DEFINITION..................................................................................................................................18
EPIDEMIOLOGY...........................................................................................................................19
TRANSMISSION............................................................................................................................20
CLINICAL MANIFESTATIONS....................................................................................................22
DIAGNOSIS....................................................................................................................................25
DIFFERENTIAL DIAGNOSIS.......................................................................................................26
TREATMENT.................................................................................................................................27
COMPLICATION...........................................................................................................................28
PROGNOSIS...................................................................................................................................28
PREVENTION................................................................................................................................29
REFERENCES....................................................................................................................................30

IDENTITY
Patient
Name
: RM
Birth Date
: February 1th 2014
Age
: 10 months old
Gender
: Female
Address
: Kampung Duku RT 07/04, East Jakarta
Nationality : Indonesia
Religion
: Islam
Date of admission: December 1th 2014.
Date of examination: December 1th 2014- December 5th 2014

Father

Mother

Name

Mr. S

Mrs. PW

Age

34 years old

32 years old

Job

Employee

Housewife

Nationality

Javanese

Javanese

Religion

Islam

Islam

Education

D3

High School (graduated)s

Earning/month

Approximately Rp.2.500.000,-

Address

Kampung Duku RT 07/04, East Jakarta.

ANAMNESIS
The anamnesis was taken on December 01th 2014, by alloanamnesis (from patients mother).
Chief complain : Fever since three days before admission to the hospital.
Additional complains : Cough, runny nose, diarrhea, shortness of breath.
History Of Present Ilness
A 10 months old girl came to Raden Said Sukanto Police Center Hospital with his
mother complained of fever since 3 days before admission, fever was suddenly high, the
temperature goes up and down but never been measured, she was taking paracetamol, but
there was no significant effect. Fever is not accompanied by convulsions and loss of
consciousness. Patients also do not shiver and delirious. The patient's parents also said there
was a productive cough and runny nose since 3 days before admission, sputum was mucoid,
clear and no blood. Runny nose secret was mucoid and clear.

Patient 's mother also complained since 2 days before admission the patient has
decreased appetite difficult to eat and drink.
Other than that the patient also complained of shortness of breath since 1 day before
entering the hospital , and also watery stool , liquid consistency , colored yellow , no residue ,
no mucus and no blood , 3-4 times a day , as much as approximately 1 / 4 aqua glass.
Patients with a history of febrile seizures at the age of 3 weeks and 5 months.
History Of Past Illness
Pharyngitis/Tonsilitis

Bronchitis

Pneumonia

Morbilli

Pertussis

Varicella

Diphteria

Malaria

Polio

Enteritis

Bacillary Dysentry

Amoeba Dysentry

Diarrhea

Thypoid

Worms

Surgery

Brain Concussion

Fracture

Drug Reaction

Birth History
Mothers Pregnancy History

The mother routinely checked her pregnancy to the midwife and Puskesmas. She denied any
problem noted during her pregnancy. She took vitamins routinely given.
Childs Birth History
Labor

: Puskesmas

Birth attendants

: midwife

Mode of delivery

: pervaginam

Gestation

: 38 weeks

Infant state

: healthy

Birth weight

: 3600 grams

Body length

: 51 cm

According to the mother, the baby started to cry and the baby's skin is red, no
congenital defects were reported
Development History
First dentition: 6 months
Psychomotor development

Head Up

: 1 month old

Smile

: 1 month old

Laughing

: 1- 2 month old

Slant

: 2,5 month old

Speech Initation

: 5 month old

Prone Position

Food Self

Sitting

Crawling

: 8 month old

Standing

: *not able to until present time*

Walking

: *not able to until present time*

: 5 month old
: 5 6 month old
: 6 month old

Mental Status:Normal
Conclusion: Growth and development status is still in the normal limits and was
appropriate according to the patients age
4

History of Eating

Breast Milk : Exclusively 6 month..

Formula milk : Bebelac since 1 month ago

Baby biscuits : Biscuits regal

Fruit and vegetables : Banana, Papaya

Solid foods and side dishes : White ricee, Carrots, Potatoes

Immunization History
Immunization

Frequency

Time

BCG

1 time

1 month old

Hepatitis B

3 times

0, 1, 6 months old

DPT

3 times

2, 4, 6 months old

Polio

4 times

Morbilli

0, 2, 4, 6 months old
-

Family History

Patients both parents were married when they were 21 years old and 19 years old,
and this is their first marriage.

There are not any significant illnesses or chronic illnesses in the family declared.

History of her brothers

No
1.

Childbirth

Gender

Spontan pervaginam,

Boy

3.

Age Died

Sumption Died

6 years old

gestation aterm
Spontan pervaginam,

2.

Age

Girl

4 years old

Girl

10 month

gestation aterm
Spontan pervaginam,
gestation aterm

The patient is the third child of three brothers.

Born died : ( - )
5

 Child dies : ( - )
Miscarriage : ( - )
History of Disease in Other Family Members / Around the House
There is no one living around their home known for having the same condition as the patient.

Sosial and Economic History

The patient lived at the house with size 10 m x 8 m together with father and mother.
There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in which 1
room is the bedroom of three of them and 1 room is for guest. There are 4 windows

inside the house. The windows are ocassionaly opened during the day.
Hygiene:
o The patient changes his clothes everyday with clean clothes.
o Bed sheets changed every two weeks.

PHYSICAL EXAMINATION (December 1th 2014)

General Status
-

General condition
Awareness
Pulse
Breathing rate
Temperature

: mild ill
: Compos Mentis
: 105 x/min, regular, full, strong.
: 26x/min
: 38,7oC (per axilla)

Antropometry Status
- Weight
- Height

: 9 kilogram
: 69 cm

Nutritional Status based NCHS (National Center for Health Statistics) year 2000:
WFA (Weight for Age): 9/8,9 x 100 % = 101 % ( good nutrition)
HFA (Height for Age): 69/71 x 100 % = 97 % (good nutrition)
WFH (Weight for Height): 9/8 x 100 % = 112 % (normal)
Conclusion: The patient has good nutritional status.

Head to Toe Examination

Head
Normocephaly, hair (black, normal distributon, not easily removed ) sign of trauma (-),
large fontanelle closed.
Eyes
Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation -/-,
sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light response ++/++
Ears
Normal shape, no wound, no bleeding ,secretion or serumen
Nose
Normal shape, midline septum, secretion +/+
Mouth

i.
ii.
iii.
iv.
1.
2.

i.

Lips: dry
Teeth: no caries
Mucous: moist
Tongue: Not dirty
Tonsils: T1/T1, No hyperemia
Pharynx: No hyperemia

Neck
Lymph node enlargement (-), scrofuloderma (-)
Thorax
:
Inspection
: symmetric when breathing , no retraction, ictus cordis is not visible
Palpation
: mass (-), tactile fremitus +/+
Percussion
: sonor on both lungs
Auscultation :
Cor
: regular S1-S2, murmur (-), gallop (-)
Pulmo : vesicular +/+, Wheezing -/- , Rhonchy -/Abdomen
:
Inspection
: Convex, epigastric retraction (-), there is no a widening of the veins, no
spider nevi.

ii. Palpation

: supple, liver and spleen not palpable, fluid wave (-), abdominal mass

(-)

iii. Percussion
iv. Auscultation
Vertebra

: The entire field of tympanic abdomen, shifting dullness (-)

: normal bowel sound, bruit (-)
: There does not appear scoliosis, kyphosis, and lordosis, do not look

any mass along the line of the vertebral

Ekstremities : warm, capillary refill time < 2 second, edema(-)
Skin
: Good turgor.

Neurological Examination
Meningeal Sign

Motoric Examination
Power
Hand
Feet
Tonus
Hand
Feet
Trophy
Hand
Feet
Physiologic Reflex
Upper extrimities
Biceps
Triceps
Lower extrimities
Patella
Achilles

5 5 5 5/ 5 5 5 5
5 5 5 5/ 5 5 5 5
Normotonus / Normotonus
Normotonus / Normotonus
Normotrophy / Normotrophy
Normotrophy / Normotrophy
+/+
+/+
+/+
+/+

Pathologic Reflex
Upper extrimities
Hoffman
Trommer

-/-/-

Lower extrimities
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer

-/-/-/-/-/-

Clonus
Patella
Achilles

-/-/9

Autonom Examination
Defecation
Urination
Sweating

Normal ( 1 times daily, normal consistency )

Normal ( 4-5 times daily )
Normal

Laboratory Investigation
Hematology December 1th 2014
Hematology

Results

Normal Value

Haemoglobin

10,1 g/dL

13-16 g/dL

Leukocytes

14.300/L

5,000 10,000/L

Hematocrits
Trombocytes

30 %
408.000/ L

40 48 %
150,000 400,000/L

Erythrocytes

4,60 million/L

4 5 million/L

Thorax Photo (December 3th 2014)

Right hilar rough
Infiltrate (+) at suprahilar dextra and sinistra.
Cor, Sinus, Diaphragma is on a normal state.
Bone and Tissue are on normal limits.
Conclusion: Susp. TB.
DD/ Bronchopneumonia

WORKING DIAGNOSIS
ISPA
DD/ Bronchopneumoni
MANAGEMENT

10

IVFD KAEN 3B, micro drip, 14 dpm 1000cc / 24 Hours.

Inj. Cefotaxime 2x500 mg IV
Paracetamol syrup 3x1 cth
Ambroxol syrup 3x1 cth

PROGNOSIS

Quo ad vitam
: dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam

FOLLOW UP December 2th 2014 - DECEMBER 5th 2014.

December 2th 2014. Second day of hospitalization, 5th day of illness
S

Fever (-)
Productive cough (+) runny nose (+)
Shortness of breath (-)
Watery stool (-)
Loss appetite

General condition: Compos mentis.

Heart rate
= 100 x/min
Respiratory rate = 25x/min
Temperature
= 36.6C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

ISPA
DD/ Bronchopneumonia

Rontgen Thorax
IVFD KAEN 3B, micro drip, 14 dpm 1000cc / 24 Hours.
Inj. Cefotaxime 2x500 mg IV
Ambroxol syrup 3x1 cth

Urinalysis December 2th 2014

Paremeter

Results

Normal Value

Macroscopik
Color

Yellow
11

Clearness
pH

Clear
6,0

5 8,5

Density

1.020

1.000-1.030

Protein

Negative

Bilirubin

Negative

Glucose

Negative

Keton

Negative

Blood / Hb

Negative

Nitrit

Negative

Urobilinogen

01

0,1 1,0 IU

Leucocyte Sedimentation

Negative

Leucocyte

1-2

/LPB

Erythrocyte

0-1

/LPB

Epitel Cell

Cylinder Cell

Crystal

Etc

Feces Examination December 2th 2014

Paremeter

Results

Normal Value

Macroscopik
Color

Green

Consistency
Mucus

Watery
+

Blood

Microscopik
Leucocyte

23

/LPB

Eryhtrocyte

01

/LPB

Ascaris Sp

Negative

Anchilostoma Sp

Negative

Trichiuris Sp

Negative

Oxyuris Sp

Negative

Jamur +

Negative

Worn Eggs

Etc

December 3th 2014. Third day of hospitalization, 6th day of illness

12

Productive cough (+)

Rash around the face, neck, chest, abdomen, back and hand.

General condition: .
Heart rate
= 124 x/min
Respiratory rate = 38x/min
Temperature
= 36.4C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/Skin: Inspection: Rash (makulopapular) at face, neck, chest, abdomen, back and
hand.

Morbili

IVFD KAEN 3B, micro drip, 14 dpm 1000cc / 24 Hours.

Inj. Cefotaxime 2x500 mg IV
Ambroxol syrup 3x1 cth
Vit A 100.000 IV

December 4th 2014, Fourth day of hospitalization, 7th day of illness

S

Productive cough (+) Runny nose (+)

Rash (+) increase
face, neck, chest, abdomen, back, and the extremities.

General condition: Compos mentis.

13

Heart rate
= 124 x/min
Respiratory rate = 38x/min
Temperature
= 36C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/Skin: Inspection: Rash (makulopapular) at face, neck, chest, abdomen, back and the
extremities.

A
P

Morbili
IVFD KAEN 3B, micro drip, 14 dpm 1000cc / 24 Hours.
Inj. Cefotaxime 2x500 mg IV
Ambroxol syrup 3x1 cth
Vit A 100.000 IV

December 5th 2014. Fifth day of hospitalization, 8th day of illness

S

Still have very few rash and cough

General condition: Compos mentis.

Heart rate
= 124 x/min
Respiratory rate = 38x/min
Temperature
= 36,2C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/Skin: Inspection: Rash (makulopapular) on the skin of the extremities still visible.

14

Morbili

Patient can go home.

Vit A 100.000 IV
Ambroxol syrup 3x1 cth
Inj. Cefotaxime 2x500 mg IV

LITERATURE REVIEW
DEFINITION
Measles / Rubeola / Morbili / English Measles
It is an acute viral infection characterized by a final stage with a maculopapular rash
erupting successively over the neck and face, trunk, arms, and legs, and accompanied by a
high fever. caused by a virus in the family paramycovirus genus Morbillivirus
Measles is a leading cause of death in children worldwide increased throughout the
year . In the world each year is estimated there are 30 million people suffering from measles.
In Indonesia is estimated at more than 30,000 children die every year due to complications
caused by measles .
Programs of prevention and eradication of measles in Indonesia at this time is at a
stage of reduction to the control and prevention of outbreaks ( Exceptional Circumstances ).
The results of the examination of blood and urine samples of patients with measles during the
outbreak showed positive IgM approximately 70-100 percent . The incidence rate of all age
15

groups from routine reporting health centers and hospitals during the years 1992-1998 tended
to decrease , especially the sharp decline in all age groups . The 1997-1999 measles incidence
of investigations of outbreaks tends to increase , this is most likely related to the impact of
food and nutrition crisis , yet still need to be studied in depth and komprehensive .
Measles is highly contagious , approximately 90% of contact for people who are vulnerable
to disease . Rarely subclinical measles . Before the use of the measles vaccine , the peak
incidence at the age of 5-10 years , most adults have imun.Saat weak in the United States ,
measles occurs most often in children of school age who have not been immunized and in
adolescents and young adults who have been in immunization .
Measles is an acute viral infectious disease , infectious characterized by three stages ,
namely the catarrhal stage , the stage of eruption , and konvalesensi stage . Another name of
this disease is measles , measles , or rubeola . Transmission occurs by droplets and direct
contact with the patient . Morbili virus contained in nasopharyngeal secretions and blood
during the catarrhal stage until 24 hours after the skin rash . Usually someone will have
lifelong immunity when it has once infected by measles .

ETIOLOGY
Measles virus is derived from the genus Morbilivirus and family Paramyxoviridae.
Wild measles virus pathogens only for primata . ape Measles can also be infected through
blood or nasopharyngeal secretions of human. Hopkins , Koplan and Hinman stated that
measles does not have reservoir in animals and does not lead to a career in humans.
Measles virion sphere -shaped , pleomorphic , and having a cover ( envelope ) with a
diameter of 100-250 nm . Virion consists of nukleocapsid ie helix of the protein RNA and
cover having short protrusions on surface . This short Tonjoian called pepfomer , and consists
of haemagglutinin ( H ) pepiomer shaped buiat and fusion ( F ) peplomer the shaped like a
bell ( dumbbell -shaped ) . Bera.t molekui of single -stranded RNA is 4.5 X 106.
Measles virus structural proteins consist of 6 , 3 members of the RNA that is
nucleoprotein ( N ) , the polymerase protein ( P ) , and a large protein ( L ) ; 3 other proteins
associated with the viral envelope . Cover membrane consisting of M protein ( glycosylated
proteins ) associated with the lipid bilayer and the inside of 2 glycoprotein H and F3'12 .
Giikoprotein H causing virus adsorption on receptors hosts . CD46 which is the complement
regulatory protein and is widespread in primate tissues act as receptors glycoprotein H.
Glycoproteins F cause virus in the host cell , the virus penetration and hemolysis . in culture
sets virus.
16

The measles virus is very sensitive to heat and cold , fast inactivation in temperature
of 37 C and 20 " C . In addition, it will also have : iiaktif with ultraviolet light , ether , and p
- propiolactone1 trypsin . The virus remains infective in the form of droplets in the air for
several hours terutarna on circumstances and the level of humidity low.
EPIDEMIOLOGY
Measles is endemic in much of the world . In the United State the number of cases of
measles in 1990 nearly 28,000 cases . In industrialized countries , measles occurred in
children aged 5 to 10 years , while in the country developing this disease often infects
children under the age of 5 years .
The incidence of measles in Indonesia since the year 1990 - 2002 is still high around
3000 - 4000 year. Measles is the largest age < 12 months , followed age groups 1-4 and 5-14
years. The risk factors for measles are:
1. Children with immunodeficiency , such as HIV / AIDS , leukemia , or with corticosteroid
therapy .
2. The trip or a visit to the region endemic measles or contact with immigrants from endemic
areas .
3. Infants who lose antibody passive and not immunized .
Risk factors that aggravate measles that can lead to serious complications , namely :
1. Malnutrition
2. immunodeficiency
3. Vitamin A deficiency
TRANSMISSION
Measles transmission. Measles is transmitted by droplet spread , direct contact , through nasal
or throat secretions of an infected person . Period of communicability lasts from the first day before
the appearance of symptoms usually prodromal about 4 days before rash onset , a minimum of two
days after the onset of rash.

17

PATHOPHYSIOLOGY
Maximum spread of the virus is during the prodromal ( catarrhal stage ) , through
direct contact with an infected person , through droplet ( droplet infection) that comes out
when sneezing or coughing . Infected people become contagious on days 9-10 after exposure
( start the prodromal phase ).
Focus realized that when a viral infection into the blood vessels and spread onto the
surface epithelium of the oropharynx , conjunctiva , respiratory tract , skin , bladder urinary
and bowel On day 9-10 focus of infection is in the airway epithelium and conjunctiva , one to
two layers of necrosis. At that time the virus in large quantities back into the blood vessels
and lead to clinical manifestations of the respiratory system begins with complaints of cough
and cold with conjunctival membranes which appear red . Immune response that occurs is the
process of epithelial inflammation in the system respiratory tract followed with clinical
manifestations such as high fever , the child looks severe pain and a rash that spreads
throughout the body , seemed a little ulsera on buccal mucosa called Koplik spots . Finally,
maculopapular rash appears on the to 14 after the start of infection and at the time of humoral
antibodies can be detected . Furthermore, decreased immune system , as a result of delayed
hypersensitivity response against viral antigens occurs rash on the skin , this incident does not
appear in the case of deficit - T cells .
Measles virus infects the invasion pads . respiratory tract epithelial tract from the nose
to the bottom bag'an respirat and serious . local multiplication the respiratory mucosa
immediately followed by the first in which a virus viremia spread in leukocytes paoa sistern
retikukoendotelial . After necrosis the reticuloendothelial cells sejumtah regardless back and
pass the virus viremia second . Most affected cells are monocytes . Infected tissue including
the thymus , spleen . iimfe glands , liver , skin , conjunctiva and lungs . after second viremia
occurs throughout the respiratory mucosa ter'ibat in peijalanan diseases that cause symptoms
of cough and korisa . measles can directly cause croup , bronchiolitis and pneumonia , in
addition to the the presence of respiratory damage such as edema and loss of cilia cause
complications of otitis media and pneumonia After a few days after throughout the
respiratory mucosa is involved , there arose Koplik spots and then rash on the skin . Both of
these manifestations on microscopic examination showed multinucleated giant cells, inter and
intracellular edema , parakeratosis and dyskeratosis.

18

CLINICAL MANIFESTATION
The time from exposure to development of the first symptoms of measles infection
typically 8 to 12 days and from exposure to the appearance of the rash about 2 weeks. Early
appearance of diseases such as malaise , irritability , temperatures as high as 40.6 C ,
conjunctivitis with excessive lacrimation , edema of the eyelids and photophobia , and cough
heavy hard enough .
The disease is divided into 3 stages :
1. catarrhal stage ( prodromal )
This stage lasts 4-5 days . Fever is usually the first sign and settled during the
prodromal period . Heat can be peaked on day five or six that is at the peak of onset of
eruption . The temperature ranged from 38.3 C - 40 C on when the eruption of rash peak.
Sore throat , dry cough and nasal secretions often encountered during the prodromal period.
Nonpurulen conjunctivitis occurs at the end prodromal and accompanied by photophobia and
increased lacrimation . conjunctivitis will disappeared after the fever down . Spotting Koplik
is smooth white spots with thin erythematous base , which arose first in the buccal mucosa
facing towards the molars and approximately day 3 or 4 of the prodromal period can be
extended to the entire oral mucosa . Koplik spotting a sign patognomonis of measles which
usually disappears when exanthema be it is clear.

Fig . 1 Koplik spots

2. Stage eruption
Symptoms in catarrhal stage increases and raised enantem in the hard palate and the
soft palate . Then occurred macular rash erythematous papules form accompanied with
19

increasing body temperature . The rash initially generated behind the ears , in part upper
lateral nape , along the hair , and the lower back . can occur light bleeding , itching and
swollen face . The rash reached the bottom member on day three and disappeared in the order
of occurrence. Gland enlargement can occur mandibular lymph nodes and back of the neck ,
splenomegaly , diarrhea and vomiting In measles hemorrhagic type ( black measles ) ,
bleeding can occur from the mouth , nose or colon.

Figure 2. Rash Mukulopapuler

3. Stage konvalensensi
Eruption is reduced and scars older color ( hyperpigmentation ) which will eventually
go away . Besides hyperpigmentation in children Indonesia often found scaly skin .
Hyperpigmentation is a symptom pathognomonic for measles . In other diseases with
erythema or exanthema skin rash disappeared without hyperpigmentation . At this stage the
temperature decreases to be normal unless there are complications.
Following an incubation period of 10-11 days during dsawali illness with fever and
malaise . Within 24 hours of going on korisa , konjungtivltis and cough . complaint The
increased tremendously , reaching a peak on day four with skin eruption . About two days
before the rash appears Koplik spots on the buccal mucosa membranes are dealing with molar
. in The three days getting bertarnbah lesions and on the whole mucosa . fever decreased and
Koplik spots menghiiang at the end of the second day after tirnbul rash . rash form of
maculopapular eupsi redness spreading from the head ( face , forehead , hairline , ears and

20

neck stas ) to the extremities in 3 up to 4 days . In the next 3 to 4 days the rash fades in the
order occurrence .
Complications that occur in patients with measles can be caused by expansion of viral
infection , secondary infection by bacteria or both Kompiikasi that can occur include otitis
media , mastoiditis , obstructive pneumonia .faringitis and laryngctrakeobaronkitis .
Moreover, it can also occur complications the central nervous system such as acute and
subacute sclerosing ensefalomyelitis panencephaliiis ( SSPE ) . Adc suspected measles
complications , especially if heat lasts longer.
Other clinical manifestations of measles atypical and modified measles . Atypical
measles is happening to a person who measles virus vaccination die . After the prodromal
period of heat and pain for 1 or 2 days , a rash that starts from the extremities and can be
urticaria , maculopapular , vesicular or a combination of several form . Also obtained high
heat , extremity edema , hepatitis and sometimes pleural effusion . In measles serology
obtained liter high HI antibody . Canderung The disease is more severe than regular measles .
This die of measles virus vaccine used in 1963 to 1967 , then the consequence is that disease
in now can only be found in adults . Modified measles is mild measles because people still
have immunity to the virus , It This can occur in infants who still have measles antibodies
from mother or someone who gets gamma globulin after contact in patients measles . Clinical
symptoms can vary and some specific clinical symptoms such as prodromal , conjunctivitis ,
Koplik spots and rashes may not obtained .
Measles occurred in patients with cellular immune deficiency such as AIDS , patients
with malignancy therapy , or for any congenital immunodeficiency , tend to be more severe .
After these patients contact with measles , clinical symptoms appear is pneumonia giant cell
without preceded by a rash . In these cases the diagnosis clinical measles difficult to enforce .
Because patients with immunocompromised may also have a poor antibody response , then
the virus isolation is the only means of diagnosis . In developing countries , reported many
severe measles are possibly related to cellular immune response poor in children with
malnutrition . Measles also looked worse when occurs in adults . CDC report in 1991 that the
incident against measles complications are more prevalent in patients with age of 20 years
than children .

21

DIAGNOSIS
Clinical diagnosis in classical measles with symptoms of cough , korisa , spotting
Koplik and maculopapular rash that starts on the face , easy to do . Often found leukopenia
which may be related to infection viruses and leukocytes are dead
Laboratory diagnosis is useful if the clinician rarely seen a case of measles or the
possibility of atypical measles or pneumonia and encephalitis are not evident in patients with
immunocornpromised . Measles can be diagnosed in a laboratory with virus isolation ,
identification of viral antigens in tissues infected or the serological response to the measles
virus . examination antigen can be done with immunofluorescent examination of cells derived
nasal exudate or from urine sediment . Moreover, it can also be done examination by RT PCR . Virus isolation is technically sutit done and facilities for virus isolation is not always
available . In the culture of the virus, measles virus The show , which consists of a cytopathic
effect the cells that form stars, multinucleated syncytial giant cell containing intranuclear
inclusions Examination laboratory that is often used is the serological response . against
measles virus Examination of this response is used . netrafiksasi way of complement , ELISA
( enzyme-linked assay immunoosorbent ) and HI ( Hemaglutination - inhibition ) . test
netrafisasi require virus propagation in vitro is technically difficult done , so although quite
sensitive test is rarely done . HI tests less sensitive than the neutralization but good enough if
the compared between the two Kaii testing . Diagnosis of measles if there increase in
antibody titer 4 times or more . ELISA is more sensitive and easier performed , and can also
detect specific IgE against measles virus M at acute phase . ACIP ( Advisry Committee on
Immunization Practices ) recommends that the laboratory criteria for measles is serologic
tests positive for Ig M measles or a significant increase in antibody titer or acquired measles
virus isolation . Lately also developed serological tests using saliva .

Anamnesis

The presence of continuous high fever of 38.5 C or higher with a cough , runny nose
, sore swallows , red eyes and glare when in contact with light ( photophobia ) , often
followed by diarrhea. at The 4-5 days of fever skin rash preceded by rising temperatures more
higher than the original.

Physical examination

The discovery that is pathognomonic Koplik spots on the buccal mucosa in front third
molars. Then came a maculopapular rash that starts from the hairline in behind the ears , then
spreads to the face , neck , and finally to the extremities.
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laboratory

Labaroratorium examination conducted in patients with measles are :

a. peripheral blood
In peripheral blood examination can be found leukopenia during the prodromal phase
and early stages of the rash . Usually there is a marked increase of the number of leukocytes
in case of complications . If no complications , the number of leukocytes slowly increased to
normal when the rash disappears .
b . Isolation and identification of viruses
Nasopharyngeal swabs and blood samples taken from a patient 2-3 days before early
symptoms until one day after the onset of the rash is the source of the suitable for virus
isolation .
c . serology
Ascertainment of measles infection serology relies on a four-fold increase in titer
antibody between the acute phase and phase konvalensen or on the invisibility serum
antibody Measles -specific IgM in serum single material taken between 1 and 2 weeks after
the initial rash .
d . Examination for complications
In patients with complications of measles can be done with the examination
laboratory as follows :
1. Encephalitis , examination of cerebrospinal fluid protein content 48-240 mg / dL
and lymphocyte counts between 5-99 cells , the levels of blood electrolytes and Blood gas
analysis.
2. enteritis , stool examination complete
3. bronchopneumonia , conducted examination of the chest.

DIFFERENTIAL DIAGNOSIS
Measles rash must be distinguished from exanthema subitum , rubella , rubeola , infections
due to enteroviruses , and adenoviruses koksaki virus, infectious mononukleus, toxoplasmosis,
meningococcaemia , scarlet fever , rikettsia disease , serum disease , Kawasaki disease and rash due to
the drug .

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TREATMENT
Measles therapy is supportive therapy are like fluids and antipyretic. Antibiotics are
given when available secondary infection with bacteria. Prophylactic antibiotics to prevent
secondary infection is not provide value and is not recommended . Meta- analysis conducted
by Frank Shann stated behwa prophylactic antibiotics are not reduce the number of measles
mortaiitas . WHO and UNICEF recommends giving vitamin A in each measles especially
when in the state of vitamin A deficiency remains a problem . dose Recommended is 100,000
IU for children aged 6 months to 1 year and 200,000 IU for children aged 1 year or Iebih .
repeated dose the next day and 4 weeks later if obtained clinical symptoms of deficiency
Giving vitamin A. Vitamin A can reduce mortaiitas and morbidity caused by measles .
The problem that often occurs in children with measles are :
a. hyperthermia
b . Less nutrients
c . The risk of complications
Measles patients without complications can be outpatient , treatment is Symptomatic with
antipyretic administration , antitussive , expectorant , and anticonvulsants when required .
Indications of hospitalization for patients with measles are hyperpyrexia (temperature >
39C) , dehydration , seizures , oral intake is difficult or complications .
Some children need supplements of vitamin A. Children with deficiency Vitamin A is
easier to infections , including measles . WHO recommend vitamin A for all children with
measles in every country where Vitamin A deficiency is a problem and is associated with
mortality . serum with a low concentration of vitamin A found in children with measles
heavy . Ribavirin is an antiviral medication , which can help cure diseases severe measles or
when a child with a weak immune system .

COMPLICATION
In measles are common resistance is decreased so as to render easy secondary
complications such as :
1. Bronkopnemonia
Bronchopneumonia may be caused by the measles virus or by pneumococcus ,
streptococcus , staphylococcus . Bronchopneumonia can cause infant mortality was young ,
children with protein-energy malnutrition , chronic diseases such as tuberculosis patients ,
leukemia and others .
2. Neurological Complications
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Kompilkasi neurological morbili like hemiplegi , paraplegi , aphasia , mental disorder,

neuritis optica and encephalitis .
3. morbili acute encephalitis
Encephalitis is an acute morbili Exanthem arise on stage , a low mortality rate . The
incidence of encephalitis after infection morbili is 1 : 1000 cases , while encephalitis after
vaccination with live virus morbili was 1.16 per 1 million doses .
4. SSPE ( Subacute Scleroting panencephalitis )
SSPE is a disease of the central nervous system degeneration . Characterized by
symptoms that occur suddenly as a mental disorder , motor dysfunction , seizures , and
coma . Clinical journey is slow , usually die within 6 months to 3 years after the onset of
symptoms spontaneously . Nevertheless , spontaneous remission can still occur . It usually
occurs in children who suffer morbili before the age of 2 years .
Immunosuppresive measles encephalopathy
Obtained in children with morbili suffering immunologic deficiency due to malignancy or by
the use of immunosuppressive drugs
In measles are common resistance is decreased so that can happen anergy ( which was
originally a positive tuberculin test negative change ) . It shows antigen antibody that patients
lacking the ability to react to infection . Therefore the greater the risk of complications ,
especially if before the general state of poor children , such as in patients with malnutrition or
with other chronic diseases .
Complications were found in measles :
1. Acute Laryngitis
2. Pneumonia
3. Encephalitis
4. Subacute sclerosing panencephalitis ( SSPE )
5. Otitis media
6. enteritis
7. Conjunctivitis
8. Myocarditis
9. Tuberculosis

PROGNOSIS
If the patient 's general condition without disetai with complications , the prognosis is
good, but a bad prognostic in poor general condition , a child who is suffering from a chronic
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illness or if there are complications . The mortality rate has decreased in recent years to a low
level in all age groups , especially the socio- economic situation improved.

PREVENTION
Measles vaccine is part of routine immunization in children . The vaccine is usually
given in combination with mumps and German measles ( MMR vaccine / mumps , measles ,
rubella ) , injected in the thigh or upper arm . If only contains measles vaccine at the age of 9
months dibeirkan . In the form of MMR , the first dose given at 12-15 months of age , the
second dose given at age 4-6 years . In addition, patients should also be advised to rest at
least 10 days and eating nutritious foods that increase body immunity .

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