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