Patient Presentation
A 3-year-old male came to clinic with a fever to 102°F, mouth sores and a rash. The mother said that the fever had started the day before and this morning he had the rash and mouth sores. He was not taking much fluid in the morning but had been urinating. He had been previously well and there was known Hand-Foot-Mouth disease in the community.
The pertinent physical exam showed a wary male who was drooling. His temperature was 101.7° with other vital signs being normal. HEENT revealed ulcerations on the palate and tongue. His lungs were clear and abdomen was soft. He had a rash that was erythematous, blanching with papules on the trunk and extremities. On the palms and soles there were similar lesions, but some had a vesicular quality particularly on the proximal fingers. He had a few similar vesicular lesions on the buttocks. The diagnosis of Hand-Foot-Mouth disease was made and the family was counseled regarding the natural history, pain control and need for hydration.
The resident asked the attending physician afterward how these ulcerations were different from Koplik spots seen in measles. The attending said that these ulcerations were much more defined or ‘punched out” and larger. Koplik spots are usually smaller, seem to be more diffuse but still have the erythematous base. Both are white, she explained, but Koplik spots have a more bluish hue to them. She went on to say that she had seen Koplik spots be so numerous that basically they looked like a few huge plaques covering portions of the mouth. “I lived through a big measles outbreak during my residency. I saw just about every complication,” she said. She went on opining, “later in my residency, I even took care of a child from another country who had SSPE. It was so sad to see him deteriorate over even a few days. We arranged for a medical transport so he could die at home with his family. I think about these kids and family every time I have a family who doesn’t want to vaccinate their child. They haven’t seen what I have seen.”
Discussion
Measles was first described in the 9th century by an Arab physician. In 1757, Francis Home, a Scottish physician showed that measles was an infectious disease found in patient’s blood. The virus was isolated by Drs. John Enders and Thomas Peebles in Boston in 1954. In 1963, the first live virus vaccine for measles was licensed in the US.
Measles is caused by a paramyxovirus that replicates in the oral pharynx and lungs and is spread by respiratory secretions. The incubation period is 8-12 days. Clinically measles causes erythematous macules and papules that first appears on the lateral and posterior neck, and that progresses to involve the face, trunk and extremities (spreading distally). The rash fades in the same direction. Cough, coryza, Koplik spots and fever also occur. Patients are contagious from 1-2 days before the rash until 4 days after the rash. Before widespread vaccination, most children had the disease by age 15.
Subacute sclerosing panencephalitis (SSPE) is a rare, fatal neurogenerative disease that occurs several years after measles infection. Patient usually have personality changes and then deteriorate mentally and have muscle spasms. There can be typical electroencephalogram changes and elevated anti-measles antibody in the cerebrospinal fluid or serum. Typical brain biopsy histological findings are also seen. Decline varies but average survival is 2 years.
Hand Foot and Mouth is a common viral exantham caused by coxsackievirus A16, other coxsackievirus, echovirus or enterovirus The rash appears as erythematous papules or intact vesicles on the palms, soles and also buttocks. Small ulcers on the palate, uvula, tonsils and tongue are also seen. The rash resolves in 1 week. Its incubation period is 3-6 days but patients can be contagious for weeks because of fecal shedding.
A review of common viral exanthams can be found here.
Learning Point
Complications of measles occur in about 30% of cases and include:
- Blindness – especially where Vitamin A deficiency is common
- Dehydration
- Diarrhea
- Otitis media – 1 in 10
- Pneumonia – 1 in 20 – leading cause of death
- Encephalitis – 1 in 1000
- Mental retardation
- Seizures
- Sensory neuronal deafness
- Subacute sclerosing panencephalitis
- Miscarriage and preterm birth
Complications are more common in patients age 20 years.
Approximately 160,000 people die each year around the world from measles and it is probably the most deadly vaccine preventable virus.
Current data for the US shows ~160 cases of measles (Jan-August 2013), while in the world the number is ~57,000 (Jan-October 2013).
The World Health Organization has monthly updates on the epidemiology of the virus available here.
Questions for Further Discussion
1. What is the vaccination rate in your own practice?
2. What other risk factors increase the risk of acquiring measles?
Related Cases
- Disease: Hand-Foot-Mouth Disease | Viral Infections | Measles
- Symptom/Presentation: Fever and Fever of Unknown Origin | Erythematous Maculopapular Lesions
- Specialty: General Pediatrics | Infectious Diseases
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Measles and Viral Infections.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Centers for Disease Control. Overview of Measles Disease. Available from the Internet at http://www.cdc.gov/measles/about/overview.html (rev. 9/12/13, cited 11/12/13).
Centers for Disease Control. Complications of Measles. Available from the Internet at http://www.cdc.gov/measles/about/complications.html (rev. 8/30/13, cited 11/12/13).
MMWR. Measles – United States, January 1-August 24, 2013. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a2.htm (rev. 9/13/13, cited 11/12/13).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
16. Learning of students and other health care professionals is facilitated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 