Measles otherwise known as Rubeola or Morbilli is a
highly infectious and one of the most contagious respiratory
disease
It is characterised by fever, respiratory symptoms and a
maculopapular rash
It mainly affects children
ETIOLOGY
The cause of measles is the measles virus, a single-
stranded, negative-sense enveloped RNA virus of the genus
Morbillivirus within the family Paramyxoviridae.
Humans are the natural hosts of the virus; no animal
reservoirs are known to exist.
This highly contagious virus is spread by respiratory
droplets released through sneezing or coughing (which can
remain active and contagious either air borne or on
surfaces, for up to 2 hours) and inhalation of such
Risk factors for severe measles and its complications
include the following:
Malnutrition
Underlying immunodeficiency
Pregnancy
Vitamin A deficiency
EPIDEMIOLOGY
The key epidemiologic features are highlighted below:
The virus is highly contagious;in apparent infection are rare
The prevalence and age incidence are related to population
density, economic and environmental factors and the use of
an effective live virus vaccine
Measles is endemic throughout the world and epidemics
recurs every 2-3 years
WHO estimated in 2005 that there were 30-40 million
measles cases, 530, 000 deaths and 15,000-60,000 cases of
blindness caused by measles annually worldwide.
In Nigeria, suspected cases of measles in 2004 and 2005
were about 32,000 and 98,000 and death attributed were
about 600 and 2,500 in both years respectively.
An effective measles vaccine was introduced in 1963.
PATHOGENESIS
The incubation period is typically 8-12 days and may last
up to 3 weeks in adults
When infected droplets are inhaled, the virus invades the
respiratory epithelial cells, multiply there, penetrate the
mucosa and the basement membrane of the blood vessel.
The viruses are thus released into the bloodstream.
[PRIMARY VIREMIA].
It takes about 2-3 days
Primary viremia leads to subsequent infection of this RES
Following further viral replication in regional and distal
RES sites, release of virus result in secondary viremia
which occurs 5-7 days after initial infection
This secondary viremia seeds the epithelial surfaces of the
body including the skin, respiratory tract, conjuctiva
Replication occurs in the lymphocyte which aid in
dissemination
The viruses attach themselves via the
HAEMAGGLUTININ glycoprotein on the viral surfaces to
a COMPLEMENT REGULATORY PROTEIN– CD46
RECEPTOR and fuses with the cell membrane by the
action of FUSION GLYCOPROTEIN(F), this allows the
release of the viral nucleocapsid directly into the cell.
The measles virus inhibits cytokine activity- it inhibits the
action of Interferon (produced within hours in response to
viral replication) which inhibits viral replication.
At maturation, the fusion protein is activated and this
causes fusion of adjacent cell membrane resulting in the
formation of large syncytia.
Most children, however, develop T-cell mediated immunity
to measles virus in some blood vessels that control the viral
infection and produce the measles maculopapular rash, a
hypersensitivity reaction to viral antigens in the skin.
This appears about day 14 and the virus-specific immune
response is also detectable when rash appears
This last for about 1 week after which there is clearance of
the virus and fading of the rash.
However, the rash doesn’t occur in patients with
deficiencies in cell-mediated immunity
Measles infection causes immunosuppression resulting in
secondary infections which are the major cause of
morbidity and mortality
MORPHOLOGY
GROSS
Blotchy, reddish brown rash of measles virus infection on
the face, trunk and proximal extremities produced as a
result of
Dilated skin vessels
Edema
Moderate non specific mononuclear perivascular infiltrate
Koplik spots - ulcerated mucosal lesions in the oral cavity
near the opening of the stensen ducts (pathognomonic of
measles)
HISTOLOGY
Lymphoid organs have
marked follicular hyperplasia
large germinal centers
randomly distributed multinucleated giant cells – warthin-
finkeldey cells which have eosinophilic nuclear and
cytoplasmic inclusion bodies
Koplik spot:
Neutrophil exudate
Necrosis
Neovascularization(abnormal formation of new fragile
blood vessels)
Giant cells
CLINICAL FEATURES
Fever as high as 40 degrees
Coryza ( running nose)
Cough ( brazzy and husky due to laryngeal and trachea
involvement)
Conjuctivitis,
Lacrymation
Sneezing
Koplik spots
This is a spot present on the mucous membrane in the
mouth, it is pathognomic for measles. The spot appears on
the 3rd-4th day of prodromal period. One to two days before
the spot, there is intense buccal hyperemia. This spots
appear as a punctuate blue white spot on the bright red
background of the buccal mucosa opposite the lower molar Emphysema
tooth, just near the stensens duct. Obstructive laryngitis(croup)
Measles rash (generalized maculopaular erythemathous) Pnuemothorax
Just at the peak of respiratory symptoms, most especially Otitis media
on the 4th day, measles rash appears. As the temperature Subcutaneous emphysema
continues to increase, more rash appears. The rash starts on Gastrointestinal complications are
the face, spreads from the face to the neck, trunk, Diarrhoea
extremities and in very severe cases ,involve the soles of Stomatitis
the hands and feet. Severe anorexia
Maculopapular eruptions begins behind the ears and on the Cancrum oris
hairline on the forehead, gathers on the face and trunk but Severe malnutrition
not much on the extremeties. Occular complications are
Severity of the rash depends on the extent of spread and Keratitis,Xerophthalmia,blindness
confluence. Cardiac complications are
Mild rashes are scattered and not confluent, severe rashes Myocarditis, Chronic congestive failure, Inversion of T
are confluent and extends to the soles of the palms and foot. wave, Prolonged PR wave
As the rashes spreads to the extremities, Hematologic complications are
fever usually drops. Persistent fever even as rashes Thrombocytopenia,Vascular damage
spreads to the extremities indicates complications. Disseminated intravascular coagulopathy
Rashes fades in the same order of appearance leaving a CNS complications are
desquamation of the skin. Desquamation is more severe in Febrile convulsion, Acute encephalitis
malnourished children Subacute sclerosing panecephalitis
Other clinical features This is a persistent degenerative viral infection of the brain,
Anorexia occurs 7 years after measles infection and can be seen in 5
Vomiting out of 10 reported cases of measles. It causes myoclonic
Diarrhea seizures, ataxia and can lead to death.
Generalized lymphadenopathy PROGNOSIS
INVESTIGATIONS Measles is a major cause of childhood morbidity and
Viral culture- To isolate the virus mortality but most children recover.
Serology – To detect IgM and IgG antibodies to measles Prognosis is bad when there is
Full blood count- Shows levels of leucopenia and Malnutrition
thrombocytopenia Immunosuppression
Serum electrolyte, urea, and creatinine- to check for renal overcrowding
status VACCINATION
Chest Xray- To check pneumonia and Tuberculosis MMRV – Measles – Mumps – Rubella – Varicella
CSF analysis- to check for encephalitis and other cerebral DEVELOPED COUNTRIES
involvement 1ST dose – 18months
Surface swabs – For microscopy culture and sensitvity 2nd dose – 4 – 5 years to increase rates of immunity
testing. DEVELOPING COUNTRIES
DIAGNOSIS 1ST dose – 6months
Clinical diagnosis 2nd dose – 9months to increase rates of immunity
History of fever for at least 3days with one of the 3 (cough, Some cultures refuse immunization and hence have
coryza and conjuctivitis) increased
Observation of koplik spots number of cases
Laboratory diagnosis Vaccination is contraindicated in pregnancy and people
Presence of positive measles IgM antibodies with compromised immunity.
Isolation of measles virus in respiratory specimen TREATMENT
MANAGEMENT ANTIVIRAL
Admit patient and ensure adequate bed rest. Rivabarin
Ensure adequate nutrition to maintain calorie intake. SUPPORTIVE CARE
Antipyretics for fever Symptomatic treatment
Anticonvulsant for seizures Fever – acetaminophen, ibuprofen
Eye toileting and care of mouth sores Itching - calamine lotion
Vitamin A administration for babies. Bacteria superimposition - antibiotics
Antiboitics for secondary infections. Prophylactic Seizure – anticonvulsants
antiboitics is not indicated for measles SUPPLMENT TREATMENT
COMPLICATIONS VIT A
Respiratory complications are
Bronchopneumonia ‘soro concept