measels disease

1. MEASLESMEASLES
IMRAN TARIQ.IMRAN TARIQ.
UNIVERSITY COLLEGE OF PHARMACYUNIVERSITY COLLEGE OF PHARMACY
University OF THE PUNJABUniversity OF THE PUNJAB

2. Measles is…Measles is…
an acutean acute viral infectionviral infection characterized by acharacterized by a
maculopapular rashmaculopapular rash erupting successivelyerupting successively
over the neck, face, body, and extremitisover the neck, face, body, and extremitis
and accompanied by aand accompanied by a high fever.high fever.
DEFINITIONDEFINITION

3. ETIOLOGYETIOLOGY
Measles virusMeasles virus
An RNA virus of the genus Morbillivirus in the family ofAn RNA virus of the genus Morbillivirus in the family of
ParamyxoviridaeParamyxoviridae
One serotype, human’s only hostOne serotype, human’s only host
Stable antigenicityStable antigenicity
Rapidly inactivated by heat and lightRapidly inactivated by heat and light
Survival in low temperature.Survival in low temperature.

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EpidemiologyEpidemiology
Measles isMeasles is endemicendemic throughout thethroughout the
world.world.
In the past,In the past, epidemicsepidemics tended to occurtended to occur
irregularlyirregularly, appearing in the, appearing in the springspring inin
large citieslarge cities at 2-4-yr intervalsat 2-4-yr intervals as newas new
groups of susceptible children weregroups of susceptible children were
exposed.exposed.

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EpidemiologyEpidemiology (Cont.)(Cont.)
It isIt is rarely subclinicalrarely subclinical..
PriorPrior to the use of measlesto the use of measles
vaccine,vaccine, thethe peak incidencepeak incidence
waswas among childrenamong children 5-10 yr5-10 yr ofof
age.age.

6. Infection sourcesInfection sources

Patients of acute stage and viral carriers of atypicalPatients of acute stage and viral carriers of atypical
measlesmeasles
TransmissionTransmission

Highly contagious, approximately 90% of susceptibleHighly contagious, approximately 90% of susceptible
contacts acquire the disease.contacts acquire the disease.

Respiratory secretionsRespiratory secretions:: maximal dissemination of virusmaximal dissemination of virus
occurs by droplet spray during the prodromal periodoccurs by droplet spray during the prodromal period
(catarrhal stage).(catarrhal stage).

Contagious from 5 daysContagious from 5 days before symptomsbefore symptoms, 5 days, 5 days afterafter
onset of rashonset of rash

Seasons: in the spring, peak in Feb-MaySeasons: in the spring, peak in Feb-May

7. PATHOGENESIS ANDPATHOGENESIS AND
PATHOLOGYPATHOLOGY
Portal of entryPortal of entry

Respiratory tract and regional lymph nodesRespiratory tract and regional lymph nodes

Enters bloodstream (primary viraemia)Enters bloodstream (primary viraemia)  monocyte –monocyte –
phagocytephagocyte systemsystem  target organs (secondary viraemia)target organs (secondary viraemia)
Target organsTarget organs

The skin; the mucous membranes of the nasopharynx,The skin; the mucous membranes of the nasopharynx,
bronchi, and intestinal tract; and in the conjunctivaebronchi, and intestinal tract; and in the conjunctivae,, ectect
Resulting In-----Resulting In-----
1) Koplik spots and skin rash:1) Koplik spots and skin rash: serous exudation and proliferationserous exudation and proliferation
ofof endothelial cells around the capillariesendothelial cells around the capillaries
2) Conjunctivis2) Conjunctivis

8. PATHOGENESIS ANDPATHOGENESIS AND
PATHOLOGYPATHOLOGY
3)3) Laryngitis, croup, bronchitisLaryngitis, croup, bronchitis :general inflammatory reaction:general inflammatory reaction
4) Hyperplasia of lymphoid tissue:4) Hyperplasia of lymphoid tissue: multinucleated giant cellsmultinucleated giant cells
(Warthin-Finkeldey giant cells) may be found(Warthin-Finkeldey giant cells) may be found
5) Interstitial pneumonitis:5) Interstitial pneumonitis:
6) Bronchopneumonia:6) Bronchopneumonia: due to secondary bacterial infectionsdue to secondary bacterial infections
7) Encephalomyelitis:7) Encephalomyelitis: perivascular demyelinization occurs inperivascular demyelinization occurs in
areas of the brain and spinal cord.areas of the brain and spinal cord.

9. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION
Typical Manifestation:Typical Manifestation:
patients havn’t had measles immunization, or vaccine failurepatients havn’t had measles immunization, or vaccine failure
with normal immunity or those havn’t used immune globulinwith normal immunity or those havn’t used immune globulin
1. Incubation period1. Incubation period (infection to symptoms) :(infection to symptoms) :
6-18days (average 10 days)6-18days (average 10 days)
2. Prodromal period:2. Prodromal period:

3-4 days3-4 days

Non-specific symptoms: fever, malaise, anorexia,Non-specific symptoms: fever, malaise, anorexia,
headacheheadache

Classical triad:Classical triad: cough, coryza (runny nose),cough, coryza (runny nose),
conjunctivitisconjunctivitis (with(with
photophobia, lacrimation)photophobia, lacrimation)

10. Koplik spotsKoplik spots
AnAn enanthemenanthem oror red mottlingred mottling isis
usually presentusually present on the hardon the hard andand
soft palatessoft palates
thethe pathognomonic sign ofpathognomonic sign of
measlesmeasles::

11. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION
Enanthem (Koplik spots):Enanthem (Koplik spots):

Pathognomonic for measlesPathognomonic for measles

24-48 hr before rash appears24-48 hr before rash appears

1mm, grayish white dots with1mm, grayish white dots with
slight, reddish areolaeslight, reddish areolae

Buccal mucosa, opposite theBuccal mucosa, opposite the
lower 2lower 2ndnd
molarsmolars

increase within 1day and spreadincrease within 1day and spread

fade soon after rash onsetfade soon after rash onset

12. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION
Koplik spotsKoplik spots

13. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION
3. Rash period3. Rash period
3-4days3-4days
Exanthem:Exanthem:
Erythematous, non-pruritic, maculopapularErythematous, non-pruritic, maculopapular

Upper lateral of the neck, behind ears, hairline,Upper lateral of the neck, behind ears, hairline,
faceface  trunktrunk  arms and legsarms and legs feetfeet

The severity of the disease is directly related toThe severity of the disease is directly related to
the extent and confluence of the rashthe extent and confluence of the rash
,,

14. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION

15. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION

16. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION

17. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION
Temperature:Temperature:

Rises abruptly as the rash appearsRises abruptly as the rash appears

Reaches 40 or higher℃Reaches 40 or higher℃

Settles after 4-5 days – if persists, suspect secondarySettles after 4-5 days – if persists, suspect secondary
infectioninfection
Coryza, fever, and coughCoryza, fever, and cough::

Increasingly severe up to the time the rash has covered theIncreasingly severe up to the time the rash has covered the
bodybody
Lymphadenopathy (posterior cervical region, mesenteric)Lymphadenopathy (posterior cervical region, mesenteric)
splenomegaly, diarrhoea, vomitingsplenomegaly, diarrhoea, vomiting
Chest X ray:Chest X ray:

May be abnormal, even in uncomplicated casesMay be abnormal, even in uncomplicated cases

18. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION
4. Recovery period4. Recovery period
3-4days3-4days
Exanthem:Exanthem:

Fades in order of appearanceFades in order of appearance

brownish discolorationbrownish discoloration
Entire illness – 10 daysEntire illness – 10 days

19. COMPLICATIONSCOMPLICATIONS
1. Respiratory Tract1. Respiratory Tract
Laryngitis, tracheitis, bronchitisLaryngitis, tracheitis, bronchitis – due to measles– due to measles
itselfitself
Laryngotrachobronchitis (croup)Laryngotrachobronchitis (croup) –cause airway–cause airway
obstruction to require tracheostomyobstruction to require tracheostomy
Secondary pneumoniaSecondary pneumonia – immunocompromised,– immunocompromised,
malnourished patients. pneumococcus, group Amalnourished patients. pneumococcus, group A
Streptococcus, Staphylococcus aureus andStreptococcus, Staphylococcus aureus and
Haemophilus influenzae type B.Haemophilus influenzae type B.
Exacerbation of TBExacerbation of TB

20. COMPLICATIONSCOMPLICATIONS
2. Myocarditis2. Myocarditis
3. Malnutrition and Vitamin A deficiency3. Malnutrition and Vitamin A deficiency

21. COMPLICATIONSCOMPLICATIONS
4. CNS4. CNS
The incidence ofThe incidence of encephalomyelitisencephalomyelitis is 1-2/l,000 cases ofis 1-2/l,000 cases of
measlesmeasles
Onset occurs 2-5 days after the appearance of the rashOnset occurs 2-5 days after the appearance of the rash
No correlation between the severity of the rash illness andNo correlation between the severity of the rash illness and
that of the neurologic involvementthat of the neurologic involvement

Earlier - direct viral effect in CNSEarlier - direct viral effect in CNS

Later – immune response causing demyelinationLater – immune response causing demyelination

22. LABORATORY EXAMINATIONLABORATORY EXAMINATION
Isolation of measles virus from a clinical specimen (e.g.,Isolation of measles virus from a clinical specimen (e.g.,
nasopharynx, urine)nasopharynx, urine)
Significant rise in measles IgG by any standard serologicSignificant rise in measles IgG by any standard serologic
assayassay
Positive serologic test for measles IgM antibodyPositive serologic test for measles IgM antibody
Immunofluorescence detects Measles antigensImmunofluorescence detects Measles antigens
Multinucleated giant cells in smears of nasal mucosaMultinucleated giant cells in smears of nasal mucosa
Measles encephalitis – raised protein, lymphocytes in CSFMeasles encephalitis – raised protein, lymphocytes in CSF

23. DIAGNOSISDIAGNOSIS
characteristic clinical picture:characteristic clinical picture:
Measles contactMeasles contact
Koplik spotKoplik spot
Features of the skin rashFeatures of the skin rash
The relation between the eruption and feverThe relation between the eruption and fever
Laboratory confirmation is rarely neededLaboratory confirmation is rarely needed

24. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
The rash of measles must be differentiated from that ofThe rash of measles must be differentiated from that of
rubella;rubella;
roseola intantum;roseola intantum;
enteroviral infections;enteroviral infections;
scarlet fever;scarlet fever;
and drug rashes.and drug rashes.

25. Pathogen Features Rash fever Vs RashPathogen Features Rash fever Vs Rash
MeaslesMeasles Measles virus Cough coryza, conjunctivitis Red maculopapule fever for3-4daysMeasles virus Cough coryza, conjunctivitis Red maculopapule fever for3-4days
Koplik spot after the FaceKoplik spot after the Face  trunktrunk  limbs rises abruptly aslimbs rises abruptly as
2nd -3rd fever Desquamation and the rash appears2nd -3rd fever Desquamation and the rash appears
discolorationdiscoloration
RubellaRubella Rubella virus Disease is mild, postau- MaculopapuleRubella virus Disease is mild, postau- Maculopapule feverfever for1-2daysfor1-2days
ricular lymphadenopathy Facericular lymphadenopathy Face  trunktrunk  limbs low or absentlimbs low or absent
No desquamation and during the rashNo desquamation and during the rash
discolorationdiscoloration
RoseolaRoseola Human Generally well, Seizures Rose colored, spreads high fever for3-5Human Generally well, Seizures Rose colored, spreads high fever for3-5
InfantumInfantum herpesvirus 6 (5-10%) due to high to the neck and theherpesvirus 6 (5-10%) due to high to the neck and the days, ceases withdays, ceases with
fever trunk the onset of rashfever trunk the onset of rash
Scarlet feverScarlet fever Group A High fever, toxicity, Gooseflesh texture on fever for1-2daysGroup A High fever, toxicity, Gooseflesh texture on fever for1-2days
Streptococcus Angina, strawberry tongue an erythematous base higher as theStreptococcus Angina, strawberry tongue an erythematous base higher as the
Circumoral pallor, tonsillitis for 3-5 day, desquam- rash appearsCircumoral pallor, tonsillitis for 3-5 day, desquam- rash appears
ation after 1 weekation after 1 week
EnteroviralEnteroviral Echovirus, Accompanied by respiratory Scattered maculeEchovirus, Accompanied by respiratory Scattered macule oror Rash appearsRash appears
InfectionsInfections Coxsackievirus or gastrointestinal maculopapule, few during or afterCoxsackievirus or gastrointestinal maculopapule, few during or after
manifestation confluent, 1-3 days, fevermanifestation confluent, 1-3 days, fever
no desquamationno desquamation
Drug RashDrug Rash Manifestations of Urticarial, maculopapula Relates to theManifestations of Urticarial, maculopapula Relates to the

26. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Scarlet feverScarlet fever

27. TREATMENTTREATMENT
Supportive, symptom-directedSupportive, symptom-directed
Antipyretics for feverAntipyretics for fever
Bed restBed rest
Adequate fluid intakeAdequate fluid intake
Be protected from exposure to strong lightBe protected from exposure to strong light
Antibiotics for otitis media, pneumoniaAntibiotics for otitis media, pneumonia
High doses Vitamin A in severe/ potentiallyHigh doses Vitamin A in severe/ potentially
severe measles/ patients less than 2 yearssevere measles/ patients less than 2 years
100,000IU—200,000IU100,000IU—200,000IU

28. Prevention.Prevention.
Isolation precautionsIsolation precautions, especially in, especially in
hospitals and other institutions, should behospitals and other institutions, should be
maintainedmaintained from the 7th day afterfrom the 7th day after
exposureexposure untiluntil 5 days after the rash has5 days after the rash has
appeared.appeared.

29. VACCINEVACCINE
TheThe initialinitial measles immunization, usually asmeasles immunization, usually as
measles-mumps-rubella (measles-mumps-rubella (MMRMMR)) vaccinevaccine, is, is
recommendedrecommended at 12-15 mo of ageat 12-15 mo of age
MMR vaccineMMR vaccine may be given for:may be given for:
1.1. Measles postexposureMeasles postexposure
2.2. Outbreak prophylaxisOutbreak prophylaxis as early asas early as 6 mo6 mo
of ageof age..

30. VACCINEVACCINE (cont.)(cont.)
AA second immunizationsecond immunization, also as MMR, is, also as MMR, is
recommendedrecommended routinely at 4-6 yr of ageroutinely at 4-6 yr of age..
Second measles immunizationSecond measles immunization should be given to :should be given to :
1. Children who have1. Children who have not previously received thenot previously received the
second dosesecond dose should be immunized by 11-12 yr ofshould be immunized by 11-12 yr of
ageage..
2.Adolescents2.Adolescents entering college or the workforceentering college or the workforce

31. VACCINEVACCINE (cont.)(cont.)
* Measles vaccine is* Measles vaccine is not recommendednot recommended for:for:
1.1. Pregnant womenPregnant women
2. Children with2. Children with primary immunodeficiencyprimary immunodeficiency
3.3. Untreated tuberculosis, cancer, or organUntreated tuberculosis, cancer, or organ
transplantationtransplantation
4. Those receiving4. Those receiving long-term immunosuppressivelong-term immunosuppressive
therapytherapy
5.5. severely immunocompromised HIV-infectedseverely immunocompromised HIV-infected
childrenchildren

32. PREVENTIONPREVENTION
3. Postexposure Prophylaxis3. Postexposure Prophylaxis
Passive immunization with immune globulin (0.25mL/kg)Passive immunization with immune globulin (0.25mL/kg)
is effective for prevention and attenuation of measles withinis effective for prevention and attenuation of measles within
5 days of exposure.5 days of exposure.

33. THANK YOUTHANK YOU