1. 5th Annual Advocacy Project: ImmuneWise Section on Medical Students, Residents, and Fellowship Trainees 2009-2010

2. Morning Report

3. Case Presentation 4 year old female is on the illness clinic schedule Her mom reports 2 days of fever and decreased energy level

4. Case Presentation Review of Systems –Temp to 102°F –Mild headache –Eye redness –Mild congestion –Non-productive cough –No GI complaints –No rash PMHx –Healthy –Due for 4-5 year old immunizations SHx –Lives with parents –No known sick contacts –Recent travel to Disney World (about 10 days ago)

5. Case Presentation - Exam General: Cooperative, NAD but appears ill HEENT: PERRL, bilateral conjunctival erythema and watery eyes, nares patent, MMM without lesions, neck supple, no lymphadenopathy Chest: CTA bilaterally, no wheeze/rales/rhonchi; HRRR, no murmur/rub/gallop Abd: Active BS, soft, non-tender, no HSM Skin: No rash or lesions noted

6. Case Presentation Diagnosed with a viral upper respiratory infection Supportive care was discussed with the patient’s mother

7. Case Presentation The 4 year old returns the next day with a new rash… Exam is unchanged except for a blotchy, blanching erythematous maculopapular rash on her face and neck

8. Differential Diagnosis - Discussion

9. Management

10. Measles Epidemiology Humans are the only natural host Transmitted by direct contact with droplets –may contract from airborne droplets too Most common in preschool and early school- aged children with a late winter peak Vaccine licensed in 1963 Vaccine failure rate of 5% in those with only a single dose

11. Measles Epidemiology

13. Measles Clinical Presentation Incubation period of 8-12 days Symptoms and signs include: –Fever, malaise, cough –Conjunctivitis, coryza, +/- photophobia –Koplik spots on soft palate (often occur before the rash and are diagnostic) –Rash, usually day 2-3 of illness Contagious for 1-2 days before onset of symptoms until ~4 days after rash appears

14. Measles Clinical Presentation

15. Measles Diagnosis Serum sample positive for measles IgM antibody on initial presentation –Sensitivity varies - low in first 72 hours of rash –If the initial test is negative, consider repeating after the rash is present > 72 hours Significant rise in measles IgG in paired acute – convalescent samples Measles RNA in blood, throat, nasopharyngeal or urine samples (by PCR)

16. Measles Complications Complications include: –Otitis media –Croup or bronchopneumonia –Diarrhea Severe complications: –Acute encephalitis in 1/1000 cases –Death in 1-3/1000 cases Usually due to respiratory or neuro complications –Subacute sclerosing panencephalitis (SSPE) Degenerative CNS disease

17. Measles Treatment Supportive care Vitamin A –Give if vitamin A deficiency is endemic –Give in the U.S under certain conditions Consult Red Book Ribavirin –Not FDA approved, but may help those severely affected and immunocompromised

18. Measles Infection Control Vaccine given within 72 hrs of exposure my provide protection in susceptible individuals Immune globulin given within 6 days of exposure may prevent or modify measles