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Measles

 - Hyderabad
Avinash Japa

Paediatrician

Hyderabad   |   19 Aug, 2021

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Measles

Description

Measles is a viral infection that is highly contagious and is caused by morbillivirus. It usually affects children before 15 years of age.

Causes

Measles is caused when a person is exposed to the measles virus. The measles virus replicates and survives only in the human host. The infection is spread by coughing, sneezing, close personal contact or direct contact with the secretions. Transmission is through the respiratory tract or conjunctivae following contact with large droplets or small droplet aerosols in which virus is suspended. The virus droplets remain active and contagious in the air for as long as one hour. 
When an individual inhales the droplets or touches the surfaces with the droplets and then their eyes, nose or mouth, the infection is passed on. Later the virus migrates to the regional lymph nodes and reticuloendothelial system and later secondary viremia spreads. Infection with the virus causes suppression of the immune system. (Th1 immune response)

Risk Factors

The risk factors measles include 

  • Not being vaccinated for measles
  • Children with a weak immune system due to HIV/AIDS, leukemia, corticosteroid therapy irrespective of the vaccination status
  • Travelling to regions where the infection is endemic
  • Vitamin A deficiency
  • Malnutrition
  • Pregnancy

Measles Symptoms & Signs

The symptoms and signs of measles include the following and usually develop 8 - 12 days after the virus enters the body.

  • Fever
  • Cold or runny nose
  • Conjunctivitis - Inflamed and watery eyes
  • Cough - Which is usually dry and the last symptom to appear
  • Throat pain
  • Kolpik spots which are discrete red lesions with bluish white spots in the centre on the inner aspects of cheeks, may involve lips, hard palate. They appear 1-4 days prior to onset of rash and are pathognomonic
  • Measles Rash - Starts on the forehead and behind the ears and on the upper neck as red maculopapular eruptions (tiny bumps) and then spreads to cover the entire body. Patients are infectious from 3 days before to up to 4-6 days after onset of rash. The rash fades over about 7 days

Investigations

Investigations are usually not required for the diagnosis of measles, but the following tests may be done. 

  • Laboratory tests
    • Measles IgM antibodies 
    • Polymerase Chain Reaction - for isolation of the measles RNA from throat, nasal or urine specimens

The following tests may be done if complications are suspected

  • Chest X-ray - if bacterial pneumonia is suspected
  • Lumbar Puncture - if encephalitis is suspected

Diagnosis of Measles

Diagnosis is established based on medical history, clinical evaluation, and results of the investigations if any. The diagnosis is considered positive if there is a history of fever for 3 days with the presence of cough, coryza (cold), conjunctivitis, and the rash. The presence of the Koplik’s spots is also diagnostic. Confirmation can be done with the laboratory investigations.

Course & Stages

Measles goes through the following stages.

  • Stage I - Infection and Incubation - It is the first 7-14 days from the time an individual is infected. There are no signs or symptoms at this stage. Measles virus migrates to regional lymph nodes and reticuloendothelial system and other body surfaces
  • Stage II - Nonspecific illness (prodromal phase) which begins after secondary viremia and is associated with epithelial necrosis and viral shedding. Symptoms of mild to moderate fever, cold, dry cough, conjunctivitis and sore throat, general weakness develop. Koplik’s spots are seen at this stage. This stage lasts for about 2 - 4 days
  • Stage III - Acute illness and rash (exanthematous phase) - This stage presents with rash and high fever, with onset of rash antibody production begins and viral replication and symptoms begin to subside

The entire course of the disease after the initial incubation phase is about 8 - 12 days.

Treatment Options

There is no treatment for measles once it has started. Treatment only includes supportive care to manage dehydration, and other symptoms.
Prophylactic antimicrobial therapy to prevent bacterial infection is not indicated.

Medical Management

The medical management of measles includes.

  • Post Exposure Vaccination - In individuals who have not been vaccinated before, giving a vaccination within 72 hours after exposure helps to lessen the severity of measles
  • Immune serum globulins -Given to pregnant women, infants, and immunocompromised individuals within 6 days after exposure to the measles virus, as they help to prevent or lessen the severity of the infection
  • Antipyretics - To provide relief from fever. Aspirin should not be given
  • Antibiotics - If secondary infections like pneumonia or ear infections develop
  • Vitamin A supplementation - Done for children who have low levels of Vitamin A that results in a more severe disease 

Prevention of Measles 

  • Exposure to susceptible individuals to patients with measles should be avoided
  • In hospitals standard and airborne precautions to be observed for this period
  • Immunocompromised patients with measles will shed virus for the duration of illness, so isolation should be maintained throughout the disease
  • Vaccination is available for the prevention of measles. The vaccine is available as MMR -II vaccine that helps to prevent Measles, Mumps, and Rubella. The first dose of the vaccine is given at the age of 9 months and the second dose at 15 months and the booster dose is given at the age of 4 -6 years
  • If previous immunization was not done at the appropriate age two doses 4 weeks apart may be given in older children and teenagers
  • In adults who have no immunization history and who are at a risk of being exposed to the measles virus, two doses 4 weeks apart may be given
  • Apart from this, maintaining good personal hygiene, and washing hands at regular and appropriate intervals can help to minimize the risk of measles as well as other infections

Complications

The complications of measles usually occur because the virus suppresses the host’s immune system. Complications of measles are more likely to occur in immunocompromised individuals, children less than the age of 5 years and older than 20 years, malnutrition, Vitamin A deficiency, malignancy and inadequate vaccination. 

Some of the complication of measles include,

  • Giant cell Pneumonia 
  • Diarrhoea and vomiting
  • Interstitial pneumonitis,  
  • Bronchiolitis obliterans
  • Pleural effusion
  • Laryngotracheobronchitis (Croup)
  • Flaring up of tuberculosis
  • Middle ear infections, otitis media
  • Sinusitis and mastoiditis
  • Encephalitis, SSPE (Subacute Sclerosing Pan Encephalitis)
  • Keratitis – which can lead to blindness
  • Myocarditis and pericarditis
  • Liver and spleen enlargement, hepatitis
  • Appendicitis, ileocolitis, acute pancreatitis
  • Thrombocytopenia, Disseminated Intravascular Coagulation (DIC)
  • Measles during pregnancy is associated with high rates of maternal morbidity, still births, and congenital malformations.

Prognosis

The prognosis of measles is good and fatal complications are rare. Complications can develop and measles is still one of the main causes of childhood blindness and childhood mortality. Death and complications are more in young children and in individuals who have weak or compromised immune systems.

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