History
A 42-year-old woman presents to the accident and emergency department with a 1-week history of malaise and a widespread rash that started on her face and spread distally.
In addition she complains of a temperature, vomiting, diarrhoea, productive cough and painful red eyes. She has just finished a course of amoxicillin for recurrent sinusitis. Her two young children have recently had a viral illness with a rash. She was previously well with no underlying medical problems. She is admitted to a side room and referred to the dermatology team.
Examination
The patient is pyrexial with a temperature of 39.4 ̊C. She has an extensive erythema-tous maculopapular eruption, which is particularly marked on her face, neck and trunk (Fig. 78.1). Some of the papules are coalescing into plaques with central bullae.
Examination of her mouth reveals marked erythema with prominent white spots on her palate and buccal mucosae (Fig. 78.2). Her conjunctivae are erythematous and injected.
Questions
• What is the most likely diagnosis and possible complication?
• How would you confirm the diagnosis?
• Who else may need some form of treatment and what form should that take?
Medicine
This woman was obviously unwell on admission. A viral illness was suspected but a pos-sible reaction to amoxicillin was also considered. Oral fluid swab and serology confirmed a diagnosis of measles. Her two children had recently had a viral illness that was sub-sequently confirmed as measles. The patient herself had been partially vaccinated with MMR (measles, mumps, rubella) vaccine as a child. Measles is highly contagious and pass-es readily among contacts through droplet spread; the incubation period is 1–2 weeks.
Patients frequently experience a prodrome of fever and malaise with photophobia and conjunctivitis. White Koplik’s spots on the buccal mucosa/palate are virtually pathogno-monic, but not always present. The cutaneous eruption usually appears within days of the onset of symptoms, first appearing behind the ears and then spreading caudally. The rash is erythematous and mainly macular but can develop papules, which may coalesce and blister. Complications include otitis media, encephalitis and bronchopneumonia. This patient developed a chest infection as a complication of her measles; sputum culture grew Haemophilus influenzae.
Oral fluid can be collected using a foam swab and sent to the virology laboratory for rapid diagnosis of measles via RNA detection tests. IgM antibodies to measles can be detected around day 4 after the onset of the rash (90–100 per cent sensitivity) and up to 3 months thereafter. Mid-stream urine, nasopharyngeal and conjunctival swabs can also be taken to confirm the presence of measles virus. Management of measles is largely supportive and patients should be isolated, so they don’t transmit this highly infectious disease; however, patients may need admitting to hospital for treatment of any serious complications that may arise. Close contacts of those infected with measles are likely to develop the disease if they are not immune (through vaccination or previous infection). Measles is a notifiable disease in the United Kingdom so the local Consultant for Communicable Diseases should be informed.
Young children who have not yet been vaccinated but who have been exposed to measles can be given two doses of live attenuated MMR vaccine to try to prevent disease onset.
Vitamin A supplementation during the acute illness has been shown to reduce morbidity and mortality.
KEY POINTS
• Measles is highly contagious; patients are infectious 2 days prior to the onset of the rash.
• The maculopapular and erythematous rash spreads in a cephalocaudal direction.
• Patients with severe complications of measles may need treatment in hospital.
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