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- Morbillivirus, a negative sense, single strand RNA virus of the paramyxoviridae group.
- Related to other morbilliviruses infecting animals including rinderpest virus, peste des petitis ruminants virus, canine distemper virus and dolphin morbillivirus
- Measles virus (MV), also known as rubeola, a respiratory agent with subsequent viremia.
- Related paramyxoviruses: human metapneumovirus, Hendra virus, newly described agents of respiratory illness; Nipah virus cause of encephalitis.
- Until routine measles immunization, rubeola virus was the most common and highly infectious of childhood diseases.
- Still a worldwide problem especially in the developing world (95% of 89,000 deaths globally in 2016, WHO). Eradication difficult despite WHO efforts due to problems in lower-resource countries, maintaining cold-chain for the vaccine.
- United States (2018 year data): 372 cases from 16 states.
- As of April 2019: 465 cases in the U.S.
- States reporting outbreaks: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Texas, and Washington.
- Factors driving increase include:
- More travelers who acquire measles overseas and remain infectious upon returning to the U.S. →
- Further transmission in communities, especially those with higher rates of unvaccinated people.
- In the year 2014, record 667 cases as the new high in the U.S. since endemic measles eliminated from U.S. (other than imported cases) since 2000 with many cases related to cases imported from the Philippines; in 2015, large number related to the outbreak from Southern California amusement park common exposure.
- As of April 2019: 465 cases in the U.S.
- Outbreak reports, see CDC: Measles Cases and Outbreaks.
- United States (2018 year data): 372 cases from 16 states.
- Non-immunized or poor response to the vaccine.
- Most cases in the U.S. in non-immunized children/adolescents or adults.
- Exposure risk typically from traveler visiting the U.S. or just returning from visiting overseas in a country with active measles
- See WHO map for countries with active cases, most cases (2017) seen in SE Asia, China, India, Africa, Italy, Ukraine.
- Travel: developing countries, also countries with regular outbreak of measles (e.g., United Kingdom).
- Non-immunized or poor response to the vaccine.
- Typical signs and symptoms: fever, coryza, cough that is then followed by a rash [Fig 1].
- Incubation: typically 10-12 days following exposure, first symptom typically high fever and flu-like symptoms along with cough and coryza.
- Koplik spots: appear 2-3d after the onset of sx, occur on inside of mouth as tiny, bluish-white spots surround by erythema on buccal mucosa [Fig 2]. May precede the onset of rash and are pathognomonic of measles.
- Rash: typically 3-5d after illness onset as macular rash that begins on face and spreads downward to become large confluent blotches over entire body [Fig 3]. Fever may spike and then abate with the onset of rash with disappearance of viremia.
- Pts may also experience diarrhea, vomiting, lymphadenopathy, abdominal pain, pharyngitis, splenomegaly, leukopenia, and thrombocytopenia.
- The entire illness lasts up to 10-14d. Patients usually become afebrile following the onset of rash. If fever persists, suspect secondary bacterial infection.
- Clinical: usually a clinically based dx based on acute febrile illness, characteristic rash and/or Koplik spots (irregular red spots w/tiny blue-white specks on buccal/lingual mucosa) in a patient with residence or travel within an endemic country or recent exposure to index or secondary case.
- Serology: measles EIA
- IgM helpful for acute infection. Can be negative prior to rash, but typically positive at rash onset.
- IgG is used to asess immune status
- Culture: tissue/secretions may be cultured for virus and/or identified by IFA.
- Nasopharyngeal aspirate IFA offers rapid dx.
- RT-PCR: respiratory or urine samples.
- In U.S.: contact CDC Measles Virus section for diagnostic assistance (culture, PCR): T: 404-639-1156; E-Mail: firstname.lastname@example.org
- Secondary complications: otitis media, bronchopneumonia, croup, diarrhea, bronchitis.
- Most common in children < 5 yrs, adults > 20 yrs.
- Many deaths from measles occur in malnourished children succumbing to pneumonia or diarrhea.
- In low-resource countries: tuberculosis, viral infections (adenovirus, herpesviruses), other bacterial infections (S. aureus, Klebsiella, Pseudomonas).
- Pregnancy: miscarriage, pre-term delivery
- Direct measles complications less common
- Encephalomyelitis: 100/100,000 infections
- Subacute sclerosing panencephalitis (SSPE): 10/100,000
SITES OF INFECTION
- Skin/systemic: characteristic disease progression starts with a prodrome of fever, cough, coryza, conjunctivitis followed by flat macular rash fusing to form blotches first over chest/trunk then to limbs.
- Pulmonary: pneumonitis (giant-cell pneumonia) during primary measles virus infection.
- Atypical measles: now rare or nonexistent, pneumonitis as hallmark w/ hypersensitivity-like reaction in recipients of killed-measles vaccine (given in the 1960s-1970s) exposed to native measles.
- Acute encephalomyelitis occurs 1:1000 w/ 15% mortality.
- Most frequently seen neurological complication of measles.
- Two types:
- Primary acute measles encephalitis
- Direct viral CNS infection, mortality 10-25%, with 25% suffering permanent neurologic sequelae.
- May recover MV in CSF.
- Acute, post-measles encephalitis (immune-mediated)
- More common than primary measles encephalitis.
- Frequent symptoms include visual disturbances, difficulty with micturition, reduced reflexes.
- Relapses may occur in one-third.
- Primary acute measles encephalitis
- Measles inclusion body encephalitis (MIBE)
- Occurs typically in immunodeficient children ~ 1 year after measles or measles immunization.
- Native MV >> vaccine strains may cause.
- CSF usually normal.
- High anti-measles IgG in CSF.
- MV RNA may be detected in brain biopsies.
- Mortality: 75%
- Subacute sclerosing panencephalitis (SSPE): very rare, < 1:300,000 cases occurring usually 7-10 years or more after measles.
- Due to defective, persistent measles virions.
- Progressive brain inflammation leads to gradually progressive cognitive impairment, behavioral disturbances, myoclonus/spasms, seizures; subsequently gait abnormalities, speech impairment that then results in mutism, vegetative state prior to coma and death.
- Diagnostic findings:
- MRI: white matter changes in cerebral cortex and brain stem
- CSF: elevated measles IgG
- EEG: characteristic periodic spikes (Rademecker complex)
- Brain biopsy: eosinophilic inclusion bodies
- Diagnostic findings:
- Acute encephalomyelitis occurs 1:1000 w/ 15% mortality.
- Most well children may be observed without intervention.
- Supplementation: vitamin A recommended for children ill enough to be hospitalized (6mos-2yrs) or if suffering from neurological/ophthalmological complication, malnutrition or immunodeficiency (>2yrs).
- Consider vitamin A 200,000IU PO x 2d
- Repeat vitamin A dosing at 4 weeks if suffering from eye disease.
- Supportive care.
- The infection tends to be more severe than in pediatric populations.
- Some experience w/ ribavirin used parenterally (20-35mg/kg/d x 7d) in adults w/ severe pneumonitis.
- Also available by aerosol, oral routes--but little clinical data for measles.
- IV formulation may not be available in the U.S.
- Acute post-measles encephalitis: corticosteroids and/or gammaglobulin.
- May be difficult to distinguish from primary measles virus encephalitis, wherein only supportive care recommended.
- MIBE: ribavirin has been employed, variable results.
- SSPE: ribavirin and alpha-interferon (intrathecal) have been used, but no robust data to support.
- Detailed information regarding primary and secondary measles (and mumps, rubella) prevention, need for serologic testing, HCW recommendations and outbreak investigation techniques are available in the CDC 2013 guidance document.
- Primary prophylaxis: since the vaccine is a live, attenuated virus, it should not be given to individuals with severe immunosuppression.
- Vaccine contraindications: hypersensitivity to neomycin or prior measles vaccine, pregnancy, immunodeficiency states, lymphoma/leukemia, AIDS.
- Children use the two-dose schedule in the U.S.: routine vaccine w/ MMR at 12- 15 mos (once maternal antibody lost) with a booster at ages 4-6 years.
- MMR may be administered before age 4-6 years, provided more than 4 weeks have elapsed since the first dose and both doses are administered at age 12mos or beyond.
- Measles vaccine is NOT linked with the development of autism, multiple sclerosis, inflammatory bowel disease, etc.
- MMRV vaccine: may be used instead of the MMR + varicella vaccine (separately), but providers should discuss risk/benefits with parents.
- First dose: CDC recommends separate administration MMR + varicella vaccinations instead of MMRV at age 12-47 mos.
- Second dose (15 mos--12 yrs) or first dose ≥ 48mos: MMRV preferred over separate injections.
- Adults born > 1957 should receive at least one dose of measles vaccine (MMR) unless they have already had measles and are immune.
- Other risk groups: healthcare workers without documented immunity, non-pregnant women of childbearing age without evidence of immunity.
- Second dose MMR recommended: students in secondary education, healthcare workers, international travelers, measles outbreak exposure, prior immunization with killed measles vaccine or vaccination with unknown measles vaccine between 1963-1967.
- Healthcare workers born after 1957 should have documented evidence of immunity (seropositive, or 2 documented MMR doses).
- Second dose rationale: 2-5% don’t respond to initial vaccine.
- Birth prior to 1957, believed immune because of native acquired infection.
- HIV: immunization now recommended for HIV-infected persons without evidence of severe immunosuppression (as scheduled above)
- Definition of severe immunodeficiency: CD4+ < 15% at any age or CD4 count < 200 ages >5 years.
- No serious ADRs reported in children on ART with histories of immunosuppression.
- MMRV vaccine is not approved for use in any persons with HIV infection.
- Travelers: recommended before any international travel
- Infants 6 months through 11 months: 1 dose of measles vaccine [infants with only 1 dose of measles vaccine before 12 months of age, need 2 more doses of the vaccine (one dose at 12 through 15 months of age and another dose at least 28 days later)].
- Children 12 months of age or older: 2 doses separated by at least 28 days.
- Adolescents and adults who have not had measles or been vaccinated: 2 doses separated by at least 28 days.
- Post-exposure prophylaxis: new recommendations suggest all, even infants from birth, should receive if non-immune with significant exposure to measles [significant exposure = if age < 1yr, pregnant, immunocompromised or susceptible]
- Immunization: preferred if contact w/ known case in a susceptible individual without MMR contraindication within 72h of exposure.
- Immunoglobulin: if administered within 6d of exposure, may help prevent. If received ≥1 dose of MMR in the past, only administer to those with severe immunocompromising states.
- Intramuscular: 0.5 mL/kg of body weight (maximum dose = 15 mL)
- Intravenous: 400 mg/kg
- If receiving gammaglobulin, immunize 6mos thereafter to avoid antibody neutralization of vaccine.
- Measles had been considered eradicated in U.S. (2000) as the few cases were imported; however, last five-plus years have seen numerous outbreaks in the non-immune that appear to be the consequence of < 90-92% community immunization rates.
- Koplik spots may help differentiate febrile illness (like influenza) as they can be seen in prodrome prior to rash.
- HIV, immune suppression, pregnancy, cancer or vitamin A deficiency/malnutrition all risks for severe measles.
- Measles cases (suspected or confirmed) should be reported promptly to local public health authorities.
- Vaccine immunity may wane, but 95% protection commonly quoted; however since 1989 two-dose vaccine schedule used to decrease the risk of infection with 2-5% who fail to seroconvert after one dose.
- Failure of conversion may also be linked to inadequate refrigeration of the vaccine leading to loss of potency.
- In mumps outbreaks, the third dose of MMR vaccine now recommended for those at increased risk.
- Multiple large studies have not been able to link the MMR vaccine to autism, asthma, etc. The famous Wakefield Lancet paper that started the fracas has been withdrawn and the researcher physician censured and medical license pulled.
- Global statistics (WHO):
- Measles immunization has reduced the number of cases, but there is still substantial morbidity, 89,000 deaths globally (2016).
- Estimated 95% of measles now occur in low-income countries.
- Global immunization in children receiving at least one dose of measles vaccine has risen according to WHO data to 85% (2016) from 72% (2000).
Basis for recommendation
- Moss WJ. Measles. Lancet. 2017;390(10111):2490-2502. [PMID:28673424]
Comment: Thorough review includes clinical principles, pathogenesis, immunity and includes prevention/eradication discussion.
- McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-04):1-34. [PMID:23760231]
Comment: Report summarizes all recommendations since 1998. New recommendations in this version include:
1) For acceptable evidence of immunity, removing documentation of physician diagnosed disease as an acceptable criterion for evidence of immunity for measles and mumps, and including laboratory confirmation of disease as a criterion for acceptable evidence of immunity for measles, rubella, and mumps.
2) For persons with human immunodeficiency virus (HIV) infection, expanding recommendations for vaccination to all persons aged ≥12 months with HIV infection who do not have evidence of current severe immunosuppression; recommending revaccination of persons with perinatal HIV infection who were vaccinated before establishment of effective antiretroviral therapy (ART) with 2 appropriately spaced doses of MMR vaccine once effective ART has been established; and changing the recommended timing of the 2 doses of MMR vaccine for HIV-infected persons to age 12 through 15 months and 4 through 6 years.
3) For measles postexposure prophylaxis, expanding recommendations for use of immune globulin administered intramuscularly (IGIM) to include infants aged birth to 6 months exposed to measles; increasing the recommended dose of IGIM for immunocompetent persons; and recommending use of immune globulin administered intravenously (IGIV) for severely immunocompromised persons and pregnant women without evidence of measles immunity who are exposed to measles.
- American Academy of Pediatrics Committee on Infectious Diseases: Vitamin A treatment of measles. Pediatrics. 1993;91(5):1014-5. [PMID:8474793]
Comment: Guidelines based on studies suggesting treatment for very sick children or those suffering from malnutrition, immunodeficiency, or complication of infection all do better with measles infection. Note high dose of Vitamin A may cause temporary headache or nausea.
- Choisy M, Trinh ST, Nguyen TND, et al. Sero-Prevalence Surveillance to Predict Vaccine-Preventable Disease Outbreaks; A Lesson from the 2014 Measles Epidemic in Northern Vietnam. Open Forum Infect Dis. 2019;6(3):ofz030. [PMID:30863786]
Comment: The study used banked sera from Vietnamese cohorts suggest that routine serosurviellance in populations may be useful to help understand when to institute preventative immunization measures beyond the routine to prevent outbreaks.
- Lo Vecchio A, Krzysztofiak A, Montagnani C, et al. Complications and risk factors for severe outcome in children with measles. Arch Dis Child. 2019. [PMID:30636224]
Comment: Somewhat surprisingly, this study from Italy did not find an age relationship but rather CRP as a risk factor for complications. This may well contrast from what is seen in children in low resource settings, especially if malnourished.
- Orenstein WA, Hinman A, Nkowane B, et al. Measles and Rubella Global Strategic Plan 2012-2020 midterm review. Vaccine. 2018;36 Suppl 1:A1-A34. [PMID:29307367]
Comment: Update with barriers including children infected with HIV, cold-chain issues for vaccine, high contagiousness and dynamic travel along with the fact that much MV eradication has been tied to polio elimination and those grant dollars (Gates, others) may decline soon. Potential breakthrough would be new vaccine delivery system not requiring refrigeration and ability to safely immunize effectively at younger ages.
- Guerra FM, Crowcroft NS, Friedman L, et al. Waning of measles maternal antibody in infants in measles elimination settings - A systematic literature review. Vaccine. 2018;36(10):1248-1255. [PMID:29398276]
Comment: Eight studies of antibody levels in cord blood and then followed in infants suggest that insufficient maternal immunization is present in some infants well before customary immunization age.
- Wendorf KA, Winter K, Zipprich J, et al. Subacute Sclerosing Panencephalitis: The Devastating Measles Complication That Might Be More Common Than Previously Estimated. Clin Infect Dis. 2017;65(2):226-232. [PMID:28387784]
Comment: Report from California of 17 SSPE cases, particularly in unvaccinated children who acquired native infection in infancy. Median age of diagnosis = 12 years, with latency period estimated at 9.5 years (range 2.5 to 34 years). Authors argue to not allow infants especially prior to immunization travel to regions endemic for measles or consider early immunization during months of 6-11.
- Hall V, Banerjee E, Kenyon C, et al. Measles Outbreak - Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep. 2017;66(27):713-717. [PMID:28704350]
Comment: Report of cases traced to unvaccinated people (65 total cases) many in a Somali-American community with the misunderstanding that autism was tied to MMR immunization. Though multiple studies have shown no such link, this linkage continues to persist as factual in some communities.
- Liko J, Guzman-Cottrill JA, Cieslak PR. Notes from the Field: Subacute Sclerosing Panencephalitis Death - Oregon, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(1):10-1. [PMID:26765654]
Comment: Fourteen year old sucumbed to SSPE who was thought to have been vaccinated at age 8 mos in the Phillipines (probably too young to engender good immunity), and acquired native measles at age 1 year. Thought to be an extraordinary rare complicated (due to defective structural protein in virus), analysis of SSPE among persons who had measles during the 1989–1991 U.S. measles resurgence indicated an incidence of 4–11 SSPE cases per 100,000 measles cases, approximately 10 times higher than earlier estimates.
- Fisher DL, Defres S, Solomon T. Measles-induced encephalitis. QJM. 2015;108(3):177-82. [PMID:24865261]
Comment: Helpful survey article reviewing the four major types of encephalitis related ot measles virus.
- Clemmons NS, Gastanaduy PA, Fiebelkorn AP, et al. Measles - United States, January 4-April 2, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(14):373-6. [PMID:25879894]
Comment: Imported cases continue to trigger outbreaks in the US, especially in populations where parents have not had their children immunized at fairly high rates such as California. Over 80% of US-based measles are in those unvaccinated or had unknown vaccination status. Four outbreaks described this year, but 70% accounted for by one larger outbreak. These circumstances certainly highlight why continued immunization rates should be high and universal.
- Perry RT, Murray JS, Gacic-Dobo M, et al. Progress Toward Regional Measles Elimination - Worldwide, 2000-2014. MMWR Morb Mortal Wkly Rep. 2015;64(44):1246-51. [PMID:26562349]
Comment: Measles cases globally slowly decreasing, but difficult to reach eradication goals. Currently 63% of countries have > 90% vaccine coverage.
- Centers for Disease Control and Prevention (CDC). Notes from the field: measles outbreak among members of a religious community - brooklyn, new york, march-june 2013. MMWR Morb Mortal Wkly Rep. 2013;62(36):752-3. [PMID:24025758]
Comment: Story of intentionally non-immunized 17yr who acquired measles in UK, led to largest outbreak in US since 2000 with 58 cases. Over 3500 contacts had to be assessed receiving post-exposure MMR or IVIG. THis points to two key facts: the highly infectious nature without protective immunity and the significant costs driven by a single case.
- Rafat C, Klouche K, Ricard JD, et al. Severe Measles Infection: The Spectrum of Disease in 36 Critically Ill Adult Patients. Medicine (Baltimore). 2013. [PMID:23982057]
Comment: Review from France where recent measles outbreaks have been more common. In this case series, none of the patients had received two doses of MMR--hence at risk. Measles pneumonitis was the primary driver to ICU care, although the viral infection had protean manifestations. Post-infectious encephalomyelitis also seen, but less commonly.
- Keegan R, Dabbagh A, Strebel PM, et al. Comparing measles with previous eradication programs: enabling and constraining factors. J Infect Dis. 2011;204 Suppl 1:S54-61. [PMID:21666211]
Comment: Attempts at eradicating measles have not been achieved, authors review that success likely lies in societal factors in a few endemic countries compared to biological factors. Current estimates place costs of measles eradication at $5-8 billion, but factors such as concurrent polio eradication, anti-vaccine lobbyists, civil wars/terrorism and lack of perceived problem in industrialized countries as reasons slowing or preventing progress.
- Scott P, Moss WJ, Gilani Z, et al. Measles vaccination in HIV-infected children: systematic review and meta-analysis of safety and immunogenicity. J Infect Dis. 2011;204 Suppl 1:S164-78. [PMID:21666158]
Comment: Immunization appears generally safe in HIV-infected children upon review of 39 studies, but authors cite the data is limited.
- Martins CL, Garly ML, Balé C, et al. Protective efficacy of standard Edmonston-Zagreb measles vaccination in infants aged 4.5 months: interim analysis of a randomised clinical trial. BMJ. 2008;337:a661. [PMID:18653640]
Comment: Safety and efficacy of immunization as early as 4 and 1/2 months compared to usual approach at 9 months during a measles outbreak in Guinea-Bissau. Infants had 92% seroconversion, and only 0.7% of immunized infants at this earlier timeframe developed measles. There was a trend toward lower mortality but this was not significant.
- Greenaway C, Dongier P, Boivin JF, et al. Susceptibility to measles, mumps, and rubella in newly arrived adult immigrants and refugees. Ann Intern Med. 2007;146(1):20-4. [PMID:17200218]
Comment: Immigrants to Canada, found that about one-third (36%) were non-immune to either measles, mumps or rubella.
- Tierney LM, Wang KC. Images in clinical medicine. Koplik's spots. N Engl J Med. 2006;354(7):740. [PMID:16481641]
Comment: View of Koplik spots.
- Parker AA, Staggs W, Dayan GH, et al. Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States. N Engl J Med. 2006;355(5):447-55. [PMID:16885548]
Comment: Large outbreak of measles in US attributed to case imported from Romania that spread in a population of children in whom routine vaccination was refused. Epidemic reinforces the need to maintain high rates of immunization.
- Dine MS, Hutchins SS, Thomas A, et al. Persistence of vaccine-induced antibody to measles 26-33 years after vaccination. J Infect Dis. 2004;189 Suppl 1:S123-30. [PMID:15106101]
Comment: Addressing concerns about the longevity of measles immunization protection, 56 participants (77% were 2-dose recipients), all had antibodies detected by the plaque reduction neutralization (PRN) antibody assay an average of 26-33 years after the first or second dose of measles vaccine; 92% had a PRN titer considered protective (>1 : 120). These data support routine two dose immunization.
- van den Hof S, Conyn-van Spaendonck MA, van Steenbergen JE. Measles epidemic in the Netherlands, 1999-2000. J Infect Dis. 2002;186(10):1483-6. [PMID:12404165]
Comment: Large outbreak in industrialized country, with 3292 reported cases; 94% of affected patients unvaccinated. Only 1 patient had received 2 doses of vaccine. Three patients died, and 16% had complications. Herd immunity outside unvaccinated clusters was high enough to prevent further transmission. This jives with measles-associated mortality rate in the United States generally quoted as 0.3%. By contrast in some developing countries, the mortality rate of measles is as high as 10%
- Centers for Disease Control and Prevention (CDC). Measles outbreak among internationally adopted children arriving in the United States, February-March 2001. MMWR Morb Mortal Wkly Rep. 2002;51(49):1115-6. [PMID:12530709]
Comment: Report of case of child aged 10 months adopted from orphanage A in China who was taken to a Texas hospital with fever, conjunctivitis, coryza, Koplik spots, and a maculopapular rash. Measles was confirmed by serologic testing. Public health authorities in Texas notified CDC, which then collaborated with health officials in other states to contact other recently adopted children from China and their adoptive families. Contact investigations that identified 14 U.S. measles cases. Most cases in US arise from importation.
- Forni AL, Schluger NW, Roberts RB. Severe measles pneumonitis in adults: evaluation of clinical characteristics and therapy with intravenous ribavirin. Clin Infect Dis. 1994;19(3):454-62. [PMID:7811865]
Comment: Small series from Cornell of six patients with severe measles pneumonitis. One pt. died, however, the other five were thought to improve significantly in respiratory status with early administration of parenteral ribavirin.
- Sprauer MA, Markowitz LE, Nicholson JK, et al. Response of human immunodeficiency virus-infected adults to measles-rubella vaccination. J Acquir Immune Defic Syndr. 1993;6(9):1013-6. [PMID:8340890]
Comment: Report of one HIV-infected adult who developed fever, rash, coryza and conjunctivitis 12 days after measles immunization. A retrospective survey conducted by the New York City Department of Health found no complications following measles immunization of HIV-infected children.
- Kaplan LJ, Daum RS, Smaron M, et al. Severe measles in immunocompromised patients. JAMA. 1992;267(9):1237-41. [PMID:1538561]
Comment: Disease is more severe in patients with HIV, cancer or immunosuppression. Characteristic rash may be absent (27-40%) and hence delay consideration of diagnosis. These patients most commonly have fever and pneumonitis (58-80%) as most common features. Giant-cell (Hecht's Giant Cell) pneumonia with syncytia may be tip off with culture or IFA confirming since antibody production may be not reliable in this patient population.
- Rahmathullah L, Underwood BA, Thulasiraj RD, et al. Reduced mortality among children in southern India receiving a small weekly dose of vitamin A. N Engl J Med. 1990;323(14):929-35. [PMID:2205798]
Comment: Large study suggesting that prevention of vitamin A deficiency decreased mortality, probably by reducing diarrheal and pulmonary disease as a consequence of childhood illnesses such as measles.
- Gremillion DH, Crawford GE. Measles pneumonia in young adults. An analysis of 106 cases. Am J Med. 1981;71(4):539-42. [PMID:7282741]
Comment: Atypical measles occurred in recipients of formalin-inactivated measles vaccine [1963-1967] and subsequently exposed to wild-type measles virus. Sx severity worse in atypical measles. Instead of starting at the head and spreading down the body, rash of atypical measles spreads centripetally not only maculopapular, but also hemorrhagic, vesicular, or urticarial. Coryza, conjunctivitis, and Koplik spots unusual in atypical measles. However, interstitial pneumonia prominent feature of atypical measles as well as pleural effusions, extremity edema, hepatitis, hyperesthesia. Has been confused w/RMSF
Measles d3 rash
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