In the latest Clinical Problem-Solving article, a 21-year-old man presented to the emergency department with fever and rash. His fever had started about 1 week before presentation and was associated with chills, myalgia, nausea, and vomiting. He also had a headache without photophobia.
In the United States, recent declines in the rate of vaccination against measles have led to several outbreaks. Given the resurgence of measles and other vaccine-preventable diseases in the United
States, interventions are needed to reintroduce a discussion of these rare conditions into medical education so that clinicians will consider them in differential diagnoses.
- What type of virus causes measles?
Measles (or rubeola — a term derived from “rubeo,” the Latin word for “red”) is an acute viral illness that is caused by a single-stranded, enveloped RNA virus. It is classified as a member of the genus morbillivirus in the Paramyxoviridae family.
- What aspects of a patient’s history or clinical presentation should raise suspicion for measles?
Measles should be suspected in any patient who presents with fever, rash, a history of travel to endemic areas or areas known to have recent transmission, or exposure to contacts with similar symptoms or a history of exposure to measles. The classic rash in patients with measles develops in a cephalocaudal and centrifugal distribution; if this pattern is described by the patient, it may provide an important clue. The prodromal symptoms, known as the “3Cs” of measles, are cough, coryza, and conjunctivitis. Koplik’s spots are transient and are noted in only 50 to 70% of patients with measles. Headache, mild gastrointestinal symptoms, and mild cerebrospinal fluid pleocytosis are common but nonspecific symptoms.
Morning Report Questions
Q: How contagious is measles?
A: Measles is extremely contagious, and contact tracing is imperative.
Clinical measles develops in approximately 9 of 10 susceptible persons who have had close contact with a person with measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes.Transmission through aerosolized droplet nuclei has been detected in closed areas for up to 2 hours after a person with measles occupies the area. Patients are infectious for approximately 4 days before and 4 days after the onset of the rash.
Q: What are the guidelines for vaccination against measles?
A: The Advisory Committee on Immunization Practices recommends routine vaccination with two doses of measles-mumps-rubella vaccine for children, with the first dose administered at 12 to 15 months of age and the second dose administered at 4 to 6 years of age, before school entry. Two doses are recommended for unvaccinated adults who are at high risk for exposure and transmission, such as students attending colleges or other educational institutions after high school, health care personnel, and international travelers, and one dose is recommended for other adults who are 18 years of age or older. Use of the inactivated vaccine strain between 1963 and 1967 was considered to be ineffective, and persons who were vaccinated during that period should be revaccinated with live vaccine.
Vaccination against measles is not necessary if there is evidence of immunity or laboratory confirmation of prior illness.