​Kembara Xtra - Medicine - Rubeola ( Measles)

​Kembara Xtra - Medicine - Rubeola ( Measles) 
Exanthematous maculopapular rash that starts at the head and progresses inferiorly to the trunk and limbs characterizes a highly contagious, acute viral infection.
Rash is accompanied by fever and the traditional 3 Cs of cough, coryza, and conjunctivitis. Early in the course of the infection, Koplik spots are pathognomonic lesions of the oral mucosa. This condition is a serious public health issue in underdeveloped countries, where it causes major morbidity and mortality.
 Hematologic, lymphatic, immunologic, pulmonary, and cutaneous systems are influenced by the MMR vaccine, with one dosage being 93% and two doses being 97% effective against measles.
Another name for rubeola

Epidemiology 
Direct contact with infectious droplets makes it highly contagious; 90% of close contacts who are non-immune are likely to contract the disease after exposure. Droplets can float in the air for hours.
The prodromal period is when infection is most potent.
Patients with impaired immune systems are considered contagious throughout the whole course of the illness, from 4 days before symptoms to 4 days after the rash emerges.
 The incubation period is typically 12.5 days from the time of exposure until prodromal symptoms appear.
According on local vaccination policies and disease occurrence, the predominant age varies. Most cases in poor nations involve youngsters under the age of two.
Incidence
Although it is no longer regarded as an endemic illness in the US, sporadic outbreaks still happen.
● With almost 850,000 cases worldwide in 2019, measles cases reached their highest level in 23 years, while mortality worldwide increased by 50% since 2016.
94 million children missed their scheduled doses of the measles vaccine in 2020, despite the fact that the number of measles cases was declining in 2020 as a result of COVID-19 control measures. The WHO and UNICEF are anticipating more child deaths from measles than COVID-19 in Africa as a result of the measles campaigns disruption.
Subpopulations that are not fully immunized and vaccination reluctance have both contributed to the continuation of measles in the United States.


Pathophysiology and Etiology 
Through the respiratory mucosa, the measles virus enters and spreads locally. Through the bloodstream, it travels to nearby lymphatic tissues and other reticuloendothelial locations.
The measles virus belongs to the family Paramyxoviridae and is spherical, enveloped, nonsegmented, single-stranded, and negative sense RNA. The sole natural host is a human.


Risk factors for contracting the measles include:
- Insufficient immunization (2 doses)
- Visits to nations where the measles is endemic - Contact with others who have been exposed
 For measles complications or severe cases:
- Malnutrition - Immunodeficiency - Pregnancy
- A lack of vitamin A
- Age range of 5 to 20 years.

Measles vaccine (active immunization) - Vaccine is typically administered in conjunction with MMR or with additional varicella (MMRV; ProQuad). Measles is 100% preventable with adequate vaccination.
- Two doses are needed for the primary immunization.
95% of children who receive the first dosage between the ages of 12 and 15 months develop immunity.
 Second dose at the start of school (4 to 6 years old) or anytime more than 4 weeks after the initial measles vaccination; the second dose virtually usually results in immunity for the 5% of initial nonresponders.
The immunization of healthcare personnel should be confirmed, and if they are not immune, they should get the vaccine if it is not contraindicated.
- commonly occurring vaccination side effects
○ Fever
 Rare (5%), febrile seizures take place 6–12 days following vaccination. If the first vaccine is given after the age of 15 months (2), the risk of febrile seizures rises.
 A brief, mild rash resembling the measles 7 to 10 days following immunization (2%, with a lowering incidence during the second vaccination)
If an allergic reaction occurs, check for immunization; if so, a second dose is not necessary.
No evidence has been found to link the MMR vaccine and autism.
- Inhibitory conditions
Live viral vaccinations should not be administered to immunocompromised people. Vaccinate asymptomatic children with a sufficient CD4 count against the MMR.
Live vaccination is not advised during pregnancy due to the risk of infection to the fetus.
 Anaphylactic reaction to neomycin or gelatin; seek allergy testing prior to vaccination.
Anaphylaxis to eggs is not a bar to consumption.

Malnutrition and Immunosuppression are Associated Conditions


History 

 Prodromal period: typically 2 to 3 days (but maybe up to 8) before rash
- Fever: May start 8–12 days after exposure; may last until 2–3 days after the onset of the rash; temperature frequently >102°F (39–40.5°C); may cause febrile seizures; fever onset >3 days after rash predicts difficult course.
- The "3 Cs": coryza, conjunctivitis, and cough
- A cough could last for two weeks.
- Prodromal symptoms often worsen over 2 to 4 days, reaching their climax on the first day of the rash, and then going away.
Other signs and symptoms include loose stools, fatigue, agitation, photophobia (caused by iridocyclitis), a sore throat, a headache, and stomach pain.


clinical assessment 
Koplik spots are a symptom of prodromal measles and are 2- to 3-mm, gray-white, elevated lesions on the buccal mucosa with an erythematous foundation. They appear 48 hours before measles exanthem.
Exanthematous rash, which is distinctive but not pathognomonic, is a maculopapular blanching rash that starts at the hairline and ears and progresses to the hips by day two.
- Confluent erythematous patches develop over time, especially on the upper body. - Clinical improvement often happens 48 hours after the rash first emerges.
Rash disappears in 3 to 4 days, turning reddish and then finely desquamating. During the exanthematous stage, lymphadenopathy and pharyngitis may be observed.

Drug eruptions, Rubella, Mycoplasma pneumoniae infection, infectious mononucleosis, parvovirus B19 infection, roseola, enteroviruses, Rocky Mountain spotted fever, dengue, toxic shock syndrome, meningococcemia, and Kawasaki disease are among the differential diagnoses.

Laboratory Results 

Initial examinations (lab, imaging)

 Collect a sample of serum and a throat (or nasopharyngeal) swab. The most reliable way to confirm measles infection by real-time polymerase chain reaction (RT-PCR) detection of RNA is molecular testing of serum and pulmonary materials.
 IgM test from serum and saliva that is specific to the measles virus.
On the first day of exanthem, antibodies may not be detectable, but by day 3, they are generally.
- Sensitivity: 77% after 72 hours of the commencement of the rash; 100% within 4 to 11 days. If results are negative but the rash persists for more than 72 hours, try again.
IgM levels drop to undetectable ranges 4 to 8 weeks after the rash starts.
Up to 7 days after exanthem, measles virus-specific IgG may not be present; its concentration peaks 14 days afterwards.
- Confirmatory evidence includes a 4-fold rise in IgG titers 14 days after an initial titer that was assessed at least 7 days after the commencement of the rash.
Measles viral cultures are not frequently carried out.
Infrequent mild neutropenia.
 Particularly in adults, liver transaminases and pancreatic amylase may be increased.
 A chest x-ray if subsequent pneumonia is a worry.

Caution Alert public health officials to possible measles cases.


Management 

Place all measles patients in respiratory isolation for 4 days following the appearance of the rash; immunocompromised individuals should be isolated throughout the duration of the illness.
Supportive care, such as the use of antipyretics, antitussives, humidification, and increased oral fluid intake
Controlling outbreaks: A measles outbreak is defined as having just one case. All suspected (and/or verified) instances should be reported to public health authorities.
- The measles can linger in the air for several hours.
Precautions against airborne dissemination (masking, physical separation).
- Vaccinate affected or potentially exposed contacts (individuals) within 72 hours.
Infants aged 6 months to 1 year may get the monovalent vaccination; however, for sufficient immunization, 2 more doses must be administered after 12 months.
If not contraindicated, all susceptible persons age > 1 years who have been exposed to the measles may get a monovalent or combination vaccine.
Individuals who were not inoculated within 72 hours of exposure should be kept out of settings including schools, daycare centers, and hospitals (social quarantine) at least until 2 weeks after the last incidence of measles was reported.

Medication 
WHO advises taking vitamin A in daily doses for two days in a row (3).[B]:
Children under 6 months old receive 50,000 IU, children between 6 and 12 months receive 100,000 IU, and children over 12 months receive 200,000 IU.
There is no recognized antiviral treatment available.
In vitro, ribavirin is effective against the measles virus.
- In a randomized experiment involving 100 measles patients who were given ribavirin or supportive treatment, the ribavirin group's hospital stay and duration of fever were both reduced.
- Children with severe measles who are immunosuppressed have received ribavirin IV or through aerosol. FDA has not authorized use.
Antibiotics should only be given to patients who exhibit clinical symptoms of bacterial superinfection (pharyngitis/tonsillitis, purulent otitis, and pneumonia).
- Prophylactic antibiotics reduced the incidence of measles-associated pneumonia by 80% (number required to treat [NNT] = 7); use in individuals at high risk for sequelae.
 Passive immunity using immunoglobulin therapy for high-risk measles-exposed persons for whom vaccination is inadvisable:
- Young children (if administered within 72 hours of exposure, infants aged 6 to 12 months may receive the MMR vaccine in place of immunoglobulin)
The CDC recommends 0.25 mL/kg to a maximum of 15 mL for babies and pregnant women; the dose for immunocompromised is 0.5 mL/kg to a maximum of 15 mL. - Pregnant women - Severe immunosuppression - Give IM immunoglobulin within 6 days of measles exposure.

Admission 
Outpatient therapy is appropriate, save when problems arise (e.g., encephalitis, pneumonia). Inpatient setting: airborne transmission precautions for 4 days following the development of rash in otherwise healthy patients and for the length of disease in immunocompromised patients.

Take Action 

Chest or stomach pain, noisy breathing, changes in eyesight, changes in behavior, confusion, and signs of problems requiring close monitoring

Education of the Patient Follow suggested immunization schedules.
Until four days after the rash begins, avoid exposure, especially to unvaccinated children and adults, pregnant women, and people with impaired immune systems.
Until respiratory symptoms go away, stay away from possible germs.


Prognosis: Usually self-limited; favorable prognosis
3% of adults will experience pneumonia that necessitates hospitalization.
Malnourished or immunocompromised children may have high mortality rates, especially in underdeveloped nations.
The risk of measles complications is highest in pregnant women, immunocompromised patients, children under the age of five, and individuals over the age of twenty.

Complications 
GI complications: The most frequent one is diarrhea, which can result in dehydration.
 Otitis media, which can cause hearing loss (5–15%)
 Complications with the lungs:
- Bronchiolitis (5–10%)
 Is responsible for most measles-related fatalities.
 Could be bacterial or viral
- Interstitial pneumonitis (those with weakened immune systems)
- Laryngotracheobronchitis (sometimes known as "measles croup"): affects children under 2 years old.
 Neurological problems
- 2 weeks after developing a rash, acute disseminated encephalomyelitis with convulsions and neurologic abnormalities (occurs in 1/1,000 instances) appears.
- Inclusion body encephalitis is an uncommon but deadly condition that affects people with compromised cellular immunity.
Subacute sclerosing panencephalitis is a rare, fatal degenerative CNS condition brought on by a measles infection that persisted beyond a natural illness.
Presents 5 to 15 years after infection and most frequently affects people under the age of two.
 There is a decline in humoral immunity memory cells after native measles infection. The immune response to measles infection paradoxically depresses response to non-measles-virus antigens for years, making people more susceptible to pneumonia and diarrhea. In people who have had vaccinations, this has not been noted.
Vitamin A deficiency predisposes to more severe keratitis and associated consequences, which can result in permanent scarring and blindness.
Secondary bacterial infections: Measles can induce systemic secondary infection, especially in developing nations. Cardiac consequences include myocarditis and pericarditis.
 Complications, primarily pneumonia, cause death rather than the infection itself. According to the CDC, 1–2 children will die from measles for every 1,000 who contract it.
 Febrile seizures within 7–10 days of vaccination; the risk may rise if the varicella vaccine is also administered.

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