• Key Clinical Signs for Suspicion of Measles  
  • Fever: Early and high: 38.3C^o  or greater 
  • Three Cs: Cough, Coryza, and Conjunctivitis 
  • Rash: Generalized maculopapular rash of any duration
• Triage and Immediate Isolation: On suspicion of measles, triage should prioritize immediate isolation to prevent transmission. 
• PPE for Healthcare Providers: Use appropriate protective gear before examination. 

Measles is a highly contagious viral infection caused by the Measles Morbillivirus. Transmission rate is as high as 90% in susceptible exposed individuals.

• Measles, a preventable infectious disease, has seen a resurgence in recent years due to reduced rates of vaccination and transmission from travelers arriving from endemic areas.
• Measles should be suspected in any unvaccinated individual from a measles endemic country presenting with fever, cough, conjunctivitis, diarrhea, and/or rash.
• Confirmatory testing is by serum anti-measles IgM Ab or measles RNA in sputum.
• Supportive management is indicated as there is no specific antiviral treatment.
• Outpatient management is appropriate unless there are risk factors for severe infection: children <12 months, unvaccinated immunocompromised patients, pregnancy.

• Diagnosis is largely clinical, with measles infection divided into 4 stages: incubation, prodrome, exanthem and recovery:
  • The incubation period for measles is 6 to 21 days.
  • The prodrome period involves the development of fever, tachycardia, malaise, and anorexia, followed by nonpurulent conjunctivitis, cough, and coryza. These symptoms last 2-5 days and intensify in severity leading up to the appearance of the exanthem. 48 hours prior to the development of the exanthem, patients may develop Koplik spots, 1-3 mm white or gray spots with an erythematous base seen on the oral mucosa. These spots slough off as the exanthem begins to appear.
  • Measles exanthem: An erythematous morbilliform rash that starts on the face and spreads caudally, often sparing the palms and soles. The rash is initially blanching. Other symptoms include lymphadenopathy, pharyngitis, fever, and/or diarrhea.
  • Rare but severe complications of measles infection include measles encephalitis, pneumonitis, perimyocarditis, keratitis, or corneal ulceration. These complications are more common in immunocompromised patients or those <12 months of age.

Figure 1. Koplik spots. https://dermnetnz.org/search.html?q=measles Image accessed from DermNet NZ.

Figure 2. Measles exanthem. ​​https://dermnetnz.org/topics/measles Image accessed from DermNet NZ.

Figure 3. Measles exanthem. ​​https://dermnetnz.org/topics/measles Image accessed from DermNet NZ.

• Bloodwork may show leukopenia and thrombocytopenia and chest X-ray may reveal interstitial pneumonitis.
• Confirmatory testing: anti-measles IgM (serum biomarker), RT-PCR for Measles antigen (sputum sample). See this helpful guide from a laboratory in California on collection and handling details.

• A patient suspected of having measles should be placed under airborne precautions as measles can remain airborne for up to 2 hours.
• Cases should be reported to the BCCDC.
• Treatment is largely supportive with fluids, antipyretics, and treatment of complications or bacterial superinfections as appropriate.
• Although clinical data is limited, ribavirin may be used to prevent/treat severe cases of measles. A dose of 15-20mg/kg/day PO BID (total daily dose 30-40 mg/kg/day) for 1-2 weeks (optimal duration unknown) may be used for patients <12 months old with measles pneumonia and patients ≥ 12 months with severe immunosuppression or those requiring ventilation. Side effects of ribavirin may include a dose-dependent reversible anemia due to myelosuppression and increased RBC oxidative stress, in addition to bradycardia and/or elevated liver transaminases.

• For children, 2 doses of vitamin A may be beneficial in acute or severe cases. A third dose can be given 4-6 weeks later if there are clinical signs/symptoms of vitamin A deficiency.
  • <6 months old dose: 50,000 IU.
  • 6-11 months old dose: 100,000 IU.
  • ≥ 12 months old dose: 200,000 IU.
• Clinical improvement occurs about 48 hours following the emergence of ex-anthem. After 3-4 days, the skin eruption darkens, then fades.
  • There may be a persistent cough up to 2 weeks after measles.
• All unvaccinated patients should be encouraged to receive two doses of the MMR vaccine at least 4 weeks apart. Unvaccinated patients exposed to a known case of measles may receive the MMR vaccine or IVIG as post-exposure prophylaxis.
  • Patients should be educated on the safety of the MMR vaccine, addressing common myths around vaccine hesitancy.
  • MMR is an attenuated live virus vaccine that causes a relatively benign infection in the body with minimal symptoms prior to being eliminated by the immune system.
  • Common side effects are a mild truncal rash and mild fever lasting 2-3 days approximately 1-2 weeks post-injection. There may also be temporary joint pain/stiffness in older individuals who are not rubella immune.
  • Extremely rare side effects include febrile seizures (4/10,000), thrombocytopenia (ITP – 1/40,000), neck/cheek swelling, and anaphylaxis.
  • There is no evidence that the MMR vaccine causes Autism Spectrum Disorder (ASD); the time frame when ASD features begin to manifest coincides with the recommended childhood vaccine schedule.
  • Unvaccinated patients exposed to measles may receive their first dose of the MMR vaccine within 3 days for Post Exposure Prophylaxis(PEP). Between 3-6 days, consideration of IVIG (400 mg/kg) for PEP. Avoid administering both IVIG and the MMR vaccine simultaneously, as IVIG reduces the immunogenicity of MMR. Physicians should also be aware that IVIG administration delays the subsequent administration of MMRV by at least 8 months.

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4. Measles vaccines: WHO position paper. Measles and Vitamin A. 
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6. Vaccines for measles, mumps, rubella, and varicella in children.
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1. All You Need to Know About Measles: All You Need to Know About Measles –
   Rebel EM –  REBEL EM
   – Emergency Medicine Blog

   
   

2. An Update and Review of Measles for Emergency Physicians
   Alves E. March 2020
   – The Journal of Emergency Medicine.

   
   

3. Images are
   courtesy of
   – DermNet NZ