1. MEASLES
Fen Hua Chen, M.D.,PhD.
Department of Pediatrics, The Third Affiliated Hospital
Sun Yat-sen University

2. DEFINITION
Measles is…
an acute viral infection characterized by a
maculopapular rash erupting successively
over the neck, face, body, and extremitis
and accompanied by a high fever.

3. ETIOLOGY
Measles virus
An RNA virus of the genus Morbillivirus in the family of
Paramyxoviridae
One serotype, human’s only host
Stable antigenicity
Rapidly inactivated by heat and light
Survival in low temperature.

4. EPIDEMIOLOGY
Infection sources
 Patients of acute stage and viral carriers of atypical
measles
Transmission
 Highly contagious, approximately 90% of susceptible
contacts acquire the disease.
 Respiratory secretions: maximal dissemination of virus
occurs by droplet spray during the prodromal period
(catarrhal stage).
 Contagious from 5 days before symptoms, 5 days after
onset of rash
 Seasons: in the spring, peak in Feb-May

5. PATHOGENESIS AND
PATHOLOGY
Portal of entry
 Respiratory tract and regional lymph nodes
 Enters bloodstream (primary viraemia)  monocyte –
phagocyte system  target organs (secondary viraemia)
Target organs
 The skin; the mucous membranes of the nasopharynx,
bronchi, and intestinal tract; and in the conjunctivae, ect
Resulting In-----
1) Koplik spots and skin rash: serous exudation and proliferation
of endothelial cells around the capillaries
2) Conjunctivis

6. PATHOGENESIS AND
PATHOLOGY
3) Laryngitis, croup, bronchitis :general inflammatory reaction
4) Hyperplasia of lymphoid tissue: multinucleated giant cells
(Warthin-Finkeldey giant cells) may be found
5) Interstitial pneumonitis: Hecht giant cell pneumonia.
6) Bronchopneumonia: due to secondary bacterial infections
7) Encephalomyelitis: perivascular demyelinization occurs in
areas of the brain and spinal cord.
8) Subacute sclerosing panencephalitis(SSPE):
degeneration of the cortex and white matter with intranuclear
and intracytoplasmic inclusion bodies

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

8. CLINICAL MANIFESTATION
Enanthem (Koplik spots):
 Pathognomonic for measles
 24-48 hr before rash appears
 1mm, grayish white dots with
slight, reddish areolae
 Buccal mucosa, opposite the
lower 2nd molars
 increase within 1day and spread
 fade soon after rash onset

9. CLINICAL MANIFESTATION
Koplik spots

10. CLINICAL MANIFESTATION
3. Rash period
3-4days
Exanthem:
Erythematous, non-pruritic, maculopapular
 Upper lateral of the neck, behind ears, hairline,
face  trunk  arms and legs feet
 The severity of the disease is directly related to
the extent and confluence of the rash
,

11. CLINICAL MANIFESTATION

12. CLINICAL MANIFESTATION

13. CLINICAL MANIFESTATION

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

15. CLINICAL MANIFESTATION
4. Recovery period
3-4days
Exanthem:
 Fades in order of appearance
 Branny desquamation and brownish discoloration
Entire illness – 10 days

16. CLINICAL MANIFESTATION

17. CLINICAL MANIFESTATION
Atypical Manifestation:
1. Mild measles
 In patients: administered immune globulin products
during the incubation period and immunized against
measles; in infants <8mo
 Long incubation period and short prodromal phase
 Mild symptom
 No Koplik spot
 The rash tends to be faint, less macular, pinpoint
 No branny desquamation and brownish discoloration
occur as the rash fades
 No complications and short course

18. CLINICAL MANIFESTATION
2. Severe measles:
 In cases with malnutrition, hypoimmunity and secondary
infection
 Persistent hyperpyrexia, sometimes with convulsions and even
coma
Exanthem:
 Completely covered the skin
 Confluent, petechiae, ecchymoses
 The hemorrhagic type of measles (black measles), bleeding
may occur from the mouth, nose, or bowel. disseminated
intravascular coagulation (DIC)

19. CLINICAL MANIFESTATION

20. CLINICAL MANIFESTATION
3. Atypical measles syndroma:
 Recipients of killed measles virus vaccine, who later come in
contact with wild-type measles virus.
 Distinguished by high fever, severe headache, severe abdominal
pain, often with vomiting, myalgias, respiratory symptoms,
pneumonia with pleural effusion
Exanthem:
 First appears on the palms, wrists, soles, and ankles, and
progresses in a centripetal direction.
 Maculopapular  vesicular  purpuric or hemorrhagic.
 Koplik spots rarely appear

21. CLINICAL MANIFESTATION
Atypical measles syndroma

22. CLINICAL MANIFESTATION
4. Measles absent of rush
 Immunodepressed, or passive immunized recently cases and
occasionally in infants <9mo who have appreciable levels
of maternal antibody
 Non-specificity
 Difficult to diagnosis

23. COMPLICATIONS
1. Respiratory Tract
Laryngitis, tracheitis, bronchitis – due to measles
itself
Laryngotrachobronchitis (croup) –cause airway
obstruction to require tracheostomy
Secondary pneumonia – immunocompromised,
malnourished patients. pneumococcus, group A
Streptococcus, Staphylococcus aureus and
Haemophilus influenzae type B.
Exacerbation of TB

24. COMPLICATIONS
2. Myocarditis
3. Malnutrition and Vitamin A deficiency

25. COMPLICATIONS
4. CNS
The incidence of encephalomyelitis is 1-2/l,000 cases of
measles
Onset occurs 2-5 days after the appearance of the rash
No correlation between the severity of the rash illness and
that of the neurologic involvement
 Earlier - direct viral effect in CNS
 Later – immune response causing demyelination
 Significant morbidity, permanent sequelae – mental
retardation and paralysis
Subacute sclerosing panencephalitis (SSPE): extremely rare,
6-10 years after infection. Progressive dementia, fatal.
Interaction of host with defective form of virus

26. LABORATORY EXAMINATION
Isolation of measles virus from a clinical specimen (e.g.,
nasopharynx, urine)
Significant rise in measles IgG by any standard serologic assay
Positive serologic test for measles IgM antibody
Immunofluorescence detects Measles antigens
Multinucleated giant cells in smears of nasal mucosa
Low white blood cell count and a relative lymphocytosis in PB
Measles encephalitis – raised protein, lymphocytes in CSF

27. DIAGNOSIS
characteristic clinical picture:
Measles contact
Koplik spot
Features of the skin rash
The relation between the eruption and fever
Laboratory confirmation is rarely needed

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

29. Pathogen Features Rash fever Vs Rash
Measles Measles virus Cough coryza, conjunctivitis Red maculopapule fever for3-4days
Koplik spot after the Face  trunk  limbs rises abruptly as
2nd -3rd fever Desquamation and the rash appears
discoloration
Rubella Rubella virus Disease is mild, postau- Maculopapule fever for1-2days
ricular lymphadenopathy Face  trunk  limbs low or absent
No desquamation and during the rash
discoloration
Roseola Human Generally well, Seizures Rose colored, spreads high fever for3-5
Infantum herpesvirus 6 (5-10%) due to high to the neck and the days, ceases with
fever trunk the onset of rash
Scarlet fever Group A High fever, toxicity, Gooseflesh texture on fever for1-2days
Streptococcus Angina, strawberry tongue an erythematous base higher as the
Circumoral pallor, tonsillitis for 3-5 day, desquam- rash appears
ation after 1 week
Enteroviral Echovirus, Accompanied by respiratory Scattered macule or Rash appears
Infections Coxsackievirus or gastrointestinal maculopapule, few during or after
manifestation confluent, 1-3 days, fever
no desquamation
Drug Rash Manifestations of Urticarial, maculopapula Relates to the
primary disease, itching or scarlatiniform rash drugs taken

30. DIFFERENTIAL DIAGNOSIS
Scarlet fever

31. DIFFERENTIAL DIAGNOSIS
Scarlet fever

32. TREATMENT
Supportive, symptom-directed
Antipyretics for fever
Bed rest
Adequate fluid intake
Be protected from exposure to strong light
Antibiotics for otitis media, pneumonia
High doses Vitamin A in severe/ potentially
severe measles/ patients less than 2 years
100,000IU—200,000IU

33. PREVENTION
1. Quarantine period
5 days after rash appears, longer for complicated measles
2. Vaccine
The initial measles immunization is recommended at 8mo of
age
A second immunization is recommended routinely at 7yr of
age
3. Postexposure Prophylaxis
Passive immunization with immune globulin (0.25mL/kg)
is effective for prevention and attenuation of measles within
5 days of exposure.

34. THANK YOU