Measles and rubella disease

Measles
• Measles: An acute generalized infection caused by a virus called paramyxovirus.

Epidemiology
• Measles is found all over the world but it carries high fatality rate in Africa.
• The high fatality rate of measles in Africa is attributed to malnutrition and under nutrition. In malnourished children, the defence mechanisms are low and weak, so the virus has more opportunity to damage before it is arrested.
• Children are most likely to suffer from under- nutrition during weaning period.
• This is also the time when unimmunised African children get measles most.
• In Europe, most children are immunised, and few who do, are infected after the age of 5 years.
• The fatality rate of measles in Eastern Africa is between 3% and 5%.
• This is about 400 times higher than the fatality rate of measles in Europe.
• Thus, there is an urgent need to increase immunisation coverage for children under one year old to 80%.

Clinical Features of Measles
• The typical case of measles actually starts with:
o Fever
o Runny nose
o Hacking cough
o Red eyes
• After 2-4 days of these initial symptoms, the patient may develop spots within the mouth called Koplik's spots.
• Koplik's spots look like little grains of white sand surrounded by a red ring and are usually found inside the cheek toward the back of the mouth (opposite the first and second upper molars).
• The skin rash (also known as an exanthem or exanthema) appears 3-5 days after the onset of the initial symptoms.
o The rash is a flat to slightly raised (maculopapular) red rash that usually last five to six days.
o It begins at the hairline and then progresses to the face and upper neck.
o Over the next two to three days, the rash progresses downward to cover the entire body, including the hands and feet

o The rash has mostly distinct lesions, but some may overlap (become confluent).
Initially, these lesions will turn white when you press on them (blanch).
o After three to four days, they will no longer blanch.
o As the rash begins to fade, there will often be a fine flaking of the skin
(desquamation).
o The rash fades in the same order that it appears.
• The fever that occurs with measles is called a stepwise fever.
• The patient starts with a mild fever that progressively gets higher.
• Fevers often reach temperatures greater than 103 F (39.4 C).
• Some patients may have a sore throat although not as common as other symptoms.

Differential Diagnosis
• Differential diagnosis of rubelliform skin rash include:
o Rubella
o Parvovirus infection
o Enterovirus infection
o Scarlet fever
o Toxic shock syndrome

Types of Measles
1.Uncomplicated Measles
• This generally occurs in well-nourished or slightly underweight child.
• There is fever, conjunctivitis, rhinitis, cough, Koplik’s spots (or stomatitis) and skin rash.

2.Complicated Measles
• Measles occurring in a very underweight child or one with signs of malnutrition.
• This presents with:
o Dyspnoea
o Nasal flaring and
o Rapid respiration.
o Hoarseness of voice
o Barking cough
o Inspiratory stridor
o Sore mouth (stomatitis) that causes inability to suck

o Severe conjunctivitis which is often associated with vitamin A deficiency causing
>Ulceration of the eyes (xeropthalmia)
> Corneal perforation
> Blindness

o Respiratory complications such as:
>Laryngitis
>Bronchitis
> Bronchiolitis
> Croup
> Bronchopneumonia

o Other complications include:
>CNS e.g. Encephalitis
>Otitis media
>Gastroenteritis

Management of Measles
• No specific chemotherapy agent influences the course of the viraemia.
• If uncomplicated measles:
o Ensure proper fluid intake and nutritious food.
o Give paracetamol for fever if temperature is 37.50 C or above and follow up daily.
o Give a single dose of vitamin A 200,000 units orally.

• If complicated measles:
o Admit to hospital
o Provide balanced diet
o Manage complications accordingly e.g. give antibiotic for pneumonia, otitis media and croup
o Give chloramphenicol or gentamycin eye ointment
o Give vitamin A 200,000 units orally
• The only successful way of preventing the serious complication of measles is by
immunising all children at 9 month of age.

Epidemiology
• Rubella (known as German measles): Mild systemic febrile viral infection with skin rashes as cutaneous manifestation.

Epidemiology
• Rubella is less infectious than measles, and transmission occurs via the airborne route by person to person contact.
• The incubation period from exposure to development of fever is 14-21 days.
• A person with rubella remains infectious from 7 days before the onset of rash to 4-5 days afterwards.
• In Eastern Africa this congenital syndrome is not frequent, probably because most people contract the disease during childhood and develop life – long immunity.

Clinical Feature and Differential Diagnosis
• After the incubation period of 2-3 weeks, the patient may develop a mild pharyngitis, a gritty feeling in the eyes due to mild conjunctivitis, and fever.
• A macular skin rash appears on the second or third day; petechiae or papules are not common.
• The rash spreads down the face and behind the ears.
• The macules diffuse into one another, forming a generalized ‘blush’ by 2 days, and fading without desquamation in 4-5 days.
• Painful joints of the hands and feet are common in young adults.
• Often there is enlargement of lymph nodes typically the post-auricular, sub- occipital or posterior cervical group of lymph nodes.
• It is easily confused with measles and so people might give a history of a second measles infection.

Differential Diagnosis
• Differential diagnosis of rubelliform skin rash includes:
o Measles
o Parvovirus infection
o Enterovirus infection
o Scarlet fever
o Toxic shock syndrome

Complications of Rubella
• Congenital rubella may result in one or more of the following complications:
o Eye: Cataract or microphthalmia (small eyes)
o Ears: Partial of complete deafness
o Heart: Patent ductus arteriosus (PDA) and other abnormalities
o CNS: Microcephaly (small head) and mental retardation.
Encephalitis
o Hepatosplenomegally with jaundice

Management and Prevention of Rubella
• Diagnosis is based on clinical examination findings.
• Other virus specific investigations may be done in well equipped hospitals.
• No treatment is available of necessary for patient suffering from rubella.
• Pregnant women should be kept away from known cases.
• Prevention is not necessary except for pregnant women or those in whom pregnancy is a possibility.
• Immunization is possible with a live attenuated vaccine but is of less value in Africa where most children acquire natural immunity before puberty.
• This vaccine would be contraindicated in a child with immune compromise from HIV.

Posted by
Welfare Jambo