Many health care providers have never seen a case of measles because the
measles vaccine has been so effective. It is important that you as a health care
provider are familiar with the clinical presentation of measles so you can
quickly diagnose it and reduce the spread of the virus in your clinic and
community. Because it is so rare, measles has sometimes been misdiagnosed as
Kawasaki's disease, roseola, dengue, or scarlet fever. Misdiagnosis can delay
your ability to implement critical measures to stop measles from spreading
so you should consider measles in the differential diagnosis of patients with
clinically compatible symptoms. Measles should move up on your differential
diagnosis if your patient has not been vaccinated against measles, recently
traveled internationally, or may have been exposed to someone who recently
traveled abroad, or lives in or has traveled to a community where measles
cases are currently occurring. After the incubation period which is on average 11
to 12 days symptoms typically begin with a fever
and the three C's: cough, coryza, and conjunctivitis. There is a stepwise
increase in temperature which may exceed 103 degrees Fahrenheit which is 39
degrees Celsius. Two or three days after symptoms begin an astute observer may
see Koplik spots which are small white spots found on the buccal mucosa. Three
to five days after symptoms begin the characteristic measles rash breaks out.
It usually begins as a maculopapular rash or flat red spots with small raised
bumps that appear on the face at the hairline and spreads downwards to the
neck, trunk, arms, and then to the legs and feet. The spots may become confluent or
joined together as they spread from the head to the rest of the body.
It is also important to note that fever should be present when the rash starts.
This helps differentiate measles from other rash illnesses like roseola.
This picture shows a classic case of the rash caused by measles. Notice the
intensity of the maculopapular rash on the face and trunk. Measles is more
difficult to see in patients with dark skin. If the rash is accompanied by other
symptoms such as cough or conjunctivitis measles is easier to diagnose. If you
suspect that a patient has measles you should act quickly. Do not wait until lab
tests come back. Patients with measles are infectious
from four days before through four days after rash with day zero being the day
of rash onset so documenting the date when the rash first appeared is
important. Control measures must be started immediately. The three things you
need to do right away are isolate, obtain specimens, and report. Promptly isolate
the patient to a room with a door that closes to avoid disease transmission.
Ideally the patient should go into a negative pressure room if available. Make
sure that the only people assigned to take care of the isolated patient are
health care personnel with two documented doses of measles, mumps, rubella, or MMR
vaccine. Also make sure they always wear a fitted N95 mask before they enter the
patient's room. Obtain specimens for testing from patients with suspected
measles. You should collect a throat swab to detect the measles virus using a test
called PCR. You should also collect a blood specimen which is used to detect
IgM antibodies against the virus. IgM testing should only be used for patients
suspected to have measles. It should not be used to see if a patient is immune to
measles. Immediately report the suspected measles case to the health department.
Your health department will let you know where you should send the specimens. They
will work with you to identify who else was exposed and who may need
postexposure prophylaxis. People who are at high risk for complications and
therefore should be prioritized include: infants younger than one year, pregnant
women, and those with immunocompromising conditions. Most patients recover
completely from measles but some suffer from complications that can be severe
including pneumonia and encephalitis. In the decade before the U.S. measles
vaccination program began an estimated 400 to 500 people died, 48,000 people
were hospitalized, and another 1,000 were reported to develop chronic disability
from measles encephalitis. The more cases we have the greater the chance we will
see more serious outcomes associated with measles. For example, one rare but
fatal complication is subacute sclerosing panencephalitis or SSPE
which presents an average of 7 years after a case of measles. The risk of SSPE
is highest in children who get measles before they are 2 years of age. We hope
you never see a case of measles in your community. Measles is preventable through
the use of a safe and highly effective vaccine. It is important to make sure
your patients are up to date on their vaccinations. It is also important to
ensure you and other staff in your practice have been vaccinated or have
documented evidence of immunity. For information on clinical features,
diagnosis, and complications of measles visit cdc.gov/measles/hcp