All About Measles And DIfferential Diagnosis With Other Infectious DIseases

Measles is a viral infection that is passed by an air-droplet way, is characterized by cyclic course, syndromes of intoxication, catarrhal inflammation of respiratory tract, conjunctiva, and rashes on the skin.

Etiology: the measles virus is a member of the family Paramyxoviridae, genus

Morbillivirus.

Epidemiology:

1.     Source of infection – infected person during last 2 days of incubation period, catarrhal period, and 4 days period of eruption (in case of complications –10 days period of eruption).

2.     Infection is transmitted by inhalation of large and small airborne droplets.

3.     Susceptible organism – no immunized people, older than 6 month, which never had measles.

Pathogenesis:

• The primary site of infection is the respiratory epithelium and conjunctiva.

• Local replication of the virus is followed by viremia (primary).

• During this phase virus is spread by leukocytes to the reticuloendothelial systemwhere it replicates.

• Following necrosis of white blood cells, a secondary viremia occurs.

• Than:

- morphological changes in CNS, mucus membrains of the trachea, bronchi,

intestinum;

- inflammation, destruction, liberation of virus;

- secondary immune deficiency, and growth of the bacterial microflora;

- forming of complications.

• With the development of specific antibody and cell-mediated responses, viremia is terminated and the illness resolves.

Clinical presentation

1.     The incubation period is 9-17 days, in those who has received specific immunoglobulin for prevention – it may be longer (up to 21 days).

4.     Prodromal period is the next, lasting 3 to 5 days. The classic three “C’s” (cough, corryza, conjunctivitis) make their appearance. The enanthema of measles occurs, Koplick’s spots (small, bluish-gray papules on a red base) localized on entire oral mucosa. They usually disappear by the second day of the exanthema. Temperature is usually high at first day.

5.     Exanthema period: Second increase of temperature. Initial lesions are noted behind the ears on the forehead and face. During 3-4 days they spread downward, involve the trunk and extremities. The rashes consist of an erythematosus maculopapular eruption. They are initially discrete but then became confluent on the areas of initial involvement.

6.     Pigmentation period progresses in the same fashion as the appearance of the rashes. As the rashes resolves, a brownish desquamation may occur.

Classification

By the form:

Typical, by the severity:

- mild;

- moderate;

- severe (without hemorrhagic syndrome, with hemorrhagic syndrome);

Atypical:

- abortive;

- mitigious;

- hyperreactive;

- subclinical;

         - asymptomatic;

- measles in vaccinated;

- measles in person who receive antibiotics and hormones.

By the course:

- smooth (uncomplicated);

- not smooth, uneven (complicated).

Complications:

By the etiology:

- primary (due to measles virus);

- secondary (bacterial).

By the time of development:

- early (in prodromal and rushes period);

- late (in pigmentation period).

By the localization:

- respiratory system (laryngitis, laryngotracheobronchitis, pneumonia);

- digestive system (enterocolitis, colitis);

- nervous system (encephalitis, serous meningitis, encephalomyelitis);

- eyes (keratitis);

- ears (otitis media);

- skin (staphylo- or streptodermia);

- urinary system (pyelonephritis).

Complications:

viral – laryngotracheitis (croup), bronchitis, encephalitis, Giant-cell pneumonia, and diarrhea is common in infants;

secondary bacterial – otitis media, pneumonia, gingivostomatitis, pyelonephritis, diarrhea, dermatitis.

Peculiarities of measles in infants

1.     Atypical (mitigious) forms.

2.     Reduction of the disease periods.

3.     Unexpressed clinical signs (catarrhal phenomena, fever, small unabundant rashes with the shortened staging and pigmentation).

4.     Complications are more frequent.

Laboratory work-up

• Common laboratory tests are non-specific, CBC – leucopenia, lymphocytosis, eosynophylia, and thrombocytopenia (may be).

• Cytoscopic examination of smears from the pharynx – presence of typical multinuclear giant cells.

• Viral isolation is technically difficult.

• Immune enzyme analysis (ELISA) – presence of Ig M antibodies in acute period.

• Serology (DHAR, PHAR) is confirmed when fourfold or greater rise in antibody titre or the presence of specific Ig M antibodies.

Diagnosis example:

• Measles, typical form, period of exanthema, moderate severity, uncomplicated.

• Measles, typical form, period of pigmentation, severe (with hemorrhagic

syndrome), complicated by the leftside polysegmental (S4–S6) pneumonia with

obstruction syndrome, Respiratory insufficiency 2nd degree.

Differential diagnose should be performed between scarlet fever, Epstein-Barr viral infection, meningococcal sepsis, pseudotuberculosis, Kawasaki syndrome, Stevens-Johnson syndrome, adenovirus, enterovirus infection, diaper rashes (photo 1), Rheumathoid arthritis systemic form (photo 2), and allergic rashes (photo 3-10).

During prodromal period – between other upper respiratory tract viral infections.

Heat rash

Rheumathoid arthritis systemic form

Drug allergy

Drug allergy

Drug allergy

Food allergy (urticaria)

Cool allergy

Differential diagnostics of infectious rashes (exanthemas)

Signs	Measles	Rubella	Scarlet fever
Initial symptoms	catarrhal signs from upper airways, conjunctives during 2-4 days, intoxication	Increase of occipital lymph nodes, small catarrhal signs and intoxication	Acutely - intoxication, angina, regional lymphadenitis
Time of the rashes' beginning	on 4-5 days of the disease, with stages	1 day, seldom 2	1 day (in 20% - 2)
Morphology	maculopapulous	small-papulous,	small point-like
Sizes of elements	middle, large	small, middle	small
Localization	1 day - on the face 2 - on the face, trunk; 3 - on the face, trunk, limbs	on whole body, mainly on unbending surfaces of the limbs	mainly on bending surfaces of limbs, down the abdomen, lumbar region, face, lateral surfaces of the trunk, pale nose-labial triangle
Brightness and color of elements	bright red	pale-rose	bright
Further  rashes' development	pigmentation, slight hulling	disappear on 3-4 days	gradually turn pale for 4-5 days, small, lamellar hulling
Catarrhal phenomena	expressed in first 5-6 days	small, short for 1-2 days	Not typical,
Oral mucous membranes	hyperemied, friable, enanthema, Koplick’s spots	clear, sometimes single elements of enanthema	marked off, bright hyperemia, enanthema on palate, angina
Intoxication	significant, lasts 5-7 days	small or being absent	proportional to local signs, short for 1-3 days
Other symptoms	Complications (respiratory, digestive, nervous, urinary systems, eye, ears, skin)	increased and painful posterior neck and occipital lymph nodes	angina, changes on the tongue (raid, from 4-5 days "strawberry"), complications on 2-3 weeks
Laboratory criteria	leucopenia, lymphocytosis, aneosynophylia, serological reaction with measles antigen (+)	leucopenia, lymphocytosis, increase of the plasmatic cells' number, serological reactions with rubella antigen (+)	leucocytosis, shift to the left, neutrophyllosis, enlarged ESR, in pharyngeal, nasal swabs - streptococci
Signs	Pseudotubercullosis	Meningococcemia		Chickenpox
Initial symptoms	acutely with many symptoms (intoxication, intestinal changes, seldom - catarrhal signs	intoxication, develops very acutely, initial measles-like rash		Acutely, observing catarrh, intoxication, rash
Time of the rashes' beginning	on 2-8 day	first hours of the disease		On 1-2 days, appear next 3-5 days as pushes
Morphology	puncture-like, small spots, erythema	hemorrhagic "star-like" with necrosis in the centre		Polymorphic (spots, papules, vesicles, crusts)
Sizes of elements	Small, middle, large	from small to significant		middle
Localization	"hood", "mitten", "socks" signs, in skin folds, bends, around joints	buttocks, lower limbs, less - on trunk, hands, face		On whole body, on hair part of the head, seldom - on palms and soles
Brightness and color of elements	bright	hemorrhagic, bright, sometimes cyanotic		Papules are pink, vesicles - on hyperemied base
Further  rashes' development	gradually disappear for 2-5 days, small, lamellar shelling	Small, disappear gradually, significant, leave "dry" necrosis		After desquamation of the crusts - a slight pigmentation
Catarrhal phenomena	Not typical	are absent, in 30-40% on previous 2-3 days - nasopharyngitis		Moderate,
Oral mucous membranes	Possible hyperemia of the pharynx, tonsils,	hyperemia and groiness of back pharyngeal wall, hypertrophy of follicles		On pink background - polymorphic elements
Intoxication	expressed, long-lasting (2-3 weeks)	sharply expressed		Small or moderate
Other symptoms	arthritis, myocarditis, diarrhea, hepatitis, abdominal syndrome, lymphoproliferative symptom, kidneys, nervous system damage, pneumonia	meningitis, encephalitis, arthritis, iridocyclitis, endocarditis, aortitis, pneumonia, pleurisy		Seldom: generalized visceral forms, meningoencephalitis
Laboratory criteria	leucocytosis, shift to the left, high ESR, Indirect hemagglutination reaction with special diagnostic test (+), separation of Y. pseudotuberculosis from excrements	leucocytosis, shift to the left, neutrophyllosis, high ESR, in nasopharyngeal swab, thick drop of blood - meningococci		Leucopenia, lymphocytosis, serological: binding complement reaction with Chickenpox antigen (+)

Evidences for obligatory hospitalization of patients with infectious exanthema

1.     The severe form of disease, when appears need in undertaking of intensive therapy; patients with moderate forms at age before 3 years.

2.     Sick children from families with bad social-home conditions, especially in the event of impossibility of their isolation to prevent infections transmission.

3.     Absence of conditions for examination and treatment at home.

4.     Sick children from closed children institutions.

Advantages of the home treatment

1.     Possibility of additional infection by hospital bacteria is completely excluded.

2.     Realization of individual care principle for sick child is more full.

3.     Avoiding stressful reactions, which could appear in case of hospital treatment.

Treatment in home conditions is possible

1.     In conditions of isolated flat.

2.     In case of satisfactory material position of the parents.

3.     In case of parents desire to organize individual care and treatment at home.

Treatment

Noncomplicated mild, moderate measles and atypical forms do not need medicine.

1.     Bed rest up to the normalization of body temperature.

2.     Regular ventilation of the room.

3.     Adequate rehydration with oral fluids (lemon tea, raspberry tea, warm alkalic

5.     drinks).

4.     Vitaminized milk-vegetable food.

5.     Control of fever (when the temperature is more than 38.5-39 °C); in children before 2 mo and in case of perinatal CNS damage, seizures in the history, severe heart diseases – when the temperature is up to 38 °C with acetaminophen (paracetamol 10-15 mg/kg not often than every 4 hours (not more than 5 times per day) or ibuprophen 10 mg/kg per dose, not often than every 6 hours.

6.     Nasal drops (in infants before 6 mo – physiologic saline solutions as Salin; in elder children – naphtizin, rhinasolin, nasivin for children 1-2 drops 3 t.d. in the nostrils, not more than 3 days).

7.     In case of dry cough – cough suppressors (such as dextramethorphan, synecod).

8.     Mucolytics in case of the moist nonproductive cough (ambroxol, acetylcystein etc.).

9.     Looking after oral cavity (gurgling with boiled water, antiseptic fluids).

10. Looking after conjunctiva (washing with boiled water, concentrated tea, sulfacyl Na in drops).

11. Vitamin A orally.

• In case of bacterial complication – antibacterial therapy should be used.

• In case of severe episodes – corticosteroids (1-2 mg/kg for 2-3 days).

• In case of croup: mist tent with 25-30 % oxygen inhalation, antianxiety medicines, steroids and mechanical ventilation in severe cases.

• In case of meningitis:

Base therapy:

1.     Bed regimen till body temperature normalization, disappearance of general cerebral and considerable improvement of focal neurological signs, not less than 14-16 days.

2.     A diet (before stable vital functions is due to adequate parenteral infusion therapy),

3.     Brest feeding or bottle feeding by adopted formulas for infants, in the first day 1/2-1/3 of average volume with a next increase to the complete volume during 2-3rd days.

4.     A milk vegetable diet (№5) is appointed for preschoolers or school children, 5-6 times per day with the next passing to the diet №2 whether №15 (depending the age) in the recovery period;

5.     Oral fluids intake corresponds to age norms (with including the IV fluids).

6.     Antibacterial therapy: for infants at presence of concomitant bacterial infection, chronic infection, inflammatory changes in the CBC (by the broadspectrum antibiotic in average therapeutic doses, a short course).

Etiologic therapy: specific therapy is absent.

Pathogenetic therapy:

• Glucocrticoids 3-5 mg/kg (by prednisolon), course not more than 10 days.

• Vascular medicine (penthoxyphyllin, nicergolin and others like that).

• In posthypoxia period – nootrops, vitamins group B.

• In case of CSF hypertension – dehydration by 25 % MgSO4 IM, lasix 1-3 mg/kg IV or IM, acethazolamid orally

• In case of seizures – Anticonvulsant therapy: benzodiasepins (seduxenum, sibasonum) 0.3-0.5 mg/kg IV, if they are ineffective – 1 % hexenalum or thiopenthalum sodii in 3-5 mg/kg IV. Dehydration therapy: lasix 2-3 mg/kg IM or IV.

Prevention

1. Specific active immunization by MMR vaccine (measles, mumps, rubella) at age 12 months. Revaccination at 4 to 6 years or at 10 to 11 years (in Ukraine revaccination in 6 years).

2. Specific passive prophylaxis with immune serum globulin in a dose of 0.25 ml/kg as a postexposure prophylaxis.

3. Nonspecific: – isolation of ill person until 5th day of the exanthema period (if complicated by pneumonia, encephalitis – up to 10th day), isolation of contact person from 8 to 17 days (in case of the specific immunoglobulin prevention – up

to 21 day).

Key words and phrases: measles, Morbillivirus, prodromal period, exanthema period, enanthema, Koplick’s spots, maculopapular rashes, spread downward, cleaning (pigmentation) period, brownish desquamation, giant-cell pneumonia, specific and nonspecific prophylaxis.