Measles was discussed in the PedEM Morsels in 2011 and again in 2015. Sadly, measles is even more important today for us to review. While we refresh our memories about what measles may look like and can cause, let us also know what we need to do when we suspect there is a measles case in our ED. Let’s digest a Morsel about Measles Management:

Measles in 2019

• Measles is known for the 3 C’s (just like every other virus!):
  • Cough
  • Coryza
  • Conjunctivitis

• Distinguishing features may include:
  • Higher fevers and malaise.
  • Papular rash that starts at the hairline and then spreads down to trunk and extremities and can include the palms and soles.
  • Koplik Spots are pathognomonic (but occur after 3 C’s and resolve when rash develops)! [Kobaidze, 2017]

• Vaccination is SAFE and effective at preventing Measles! [CDC.gov; Halsey, 2001]
  • Measles is one of THE MOST CONTAGIOUS infectious diseases.
    • Often those who are unvaccinated/under-vaccinated, cluster geographically, further increasing risk! [Lieu, 2015]
    • In the US, vaccine refusal is associated with increased risk for measles among the unvaccinated and the vaccinated patients. [Phadke, 2016]
  • MMR vaccination is 93% effective after 1 dose and 97% effective after 2nd dose.
  • MMR is scheduled to be given at 12-15 months and then again at 4-6 years of age.

Measles: Complications

• Measles is typically a self-limited disease, but can develop complications. [Kobaidze, 2017]
  • Some will require hospitalization.
  • High risk for complications: < 5 years, > 20 years, pregnant, and immunocompromised patients.
  • EVERY ORGAN SYSTEM CAN BE INVOLVED!

• Common Complications: [Kobaidze, 2017; Casasoprana, 2014]
  • Otitis Media
  • Pneumonia
  • Croup (laryngotracheobronchitis)
  • Diarrhea

• Severe Complications (rare, but can even occur in previously healthy patients): [Kobaidze, 2017]
  • Myocarditis
  • Glomerulonephritis
  • Thrombocytopenic Pupura
  • Acute Encephalitis
  • Subacute Sclerosing PanEncephalitis
  • Death

Measles Management

• Think about it!
  • Fever + Rash should evoke measles on our DDx.
  • Look for the distinguishing features.
  • Ask about specific vaccination status!
  • Inquire about travel or exposure to others with similar fever & rash.

• Test for it! [Kobaidze, 2017]
  • Measles-specific IgM antibody in serum
  • Measles RNA detection via RT-PCR from throat/nasopharyngeal swab
  • Refer to the CDC for guidance!

• Isolate it!
  • Cases should be isolated until 4 days AFTER they develop the rash.
  • Airborne precautions are required in the healthcare setting.

• Treat symptoms![Kobaidze, 2017]
  • Supportive care (fever and hydration management) will be the main therapies.
    
  • Direct other specific therapies toward complications if present.

• Give Vitamin A for severe / hospitalized cases.
  • < 6 months – 50,000 IU
  • 6-11 months – 100,000 IU
  • >11 months – 200,000 IU

• Antiviral therapy (Ribavirin) has been investigated in high risk populations, but is not universally recommended at this time. [Kobaidze, 2017; Moulik, 2013]

• Post-Exposure Prophlyaxis [CDC.gov; Kobaidze, 2017]
  • Post-exposure prophylaxis should be offered to those who are exposed to measles and cannot prove immunity to it.
  • MMR vaccine can be given within 72 hours of exposure.
    • MMR can be given to infants 6 – 11 months in these situations.
  • Immunoglobulin can also be given up to 6 days of exposure.
    • High risk individuals should be given immunoglobulin.
    • Can be given IM (0.5 mL/kg, max = 15 mL) or IV (400 mg/kg, if >30 kg, use IM).
  • MMR and Immunoglobulin should not be given at the same time.

Moral of the Morsel

• Open those old text books people! Measles is still around (sadly)!
• Fever + Rash? Think about Measles.
• Ask about specific vaccination status and risk factors!
• Collect the specimens! Serum and Throat Swabs are helpful to not just this patient, but all of the other humans that come in contact with her/him.

References