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Measles

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Measles\: also known as rubeola, a highly contagious respiratory viral infection, noti
Incidence\: Prior to vaccination in 1968, 160,000-800,000 annual noti
2019, 808 con
At-risk groups\: more common in young children, but can a
Aetiology\: Caused by a single-stranded RNA virus (genus Morbillivirus, family Paramyxoviridae), spread through respiratory
droplets.
Infectious period\: Incubation ~10 days. Infectious from symptom onset until four days after rash appearance. Lifelong
immunity after infection.
Risk factors\: exposure to the virus, lack of prior immunisation, failure to respond to the vaccine.
Clinical features\: Prodromal phase (2-4 days) includes fever ≥39°C, cough, conjunctivitis, coryza, diarrhoea. Koplik’s spots
(pathognomonic) and erythematous maculopapular rash starting on the face.
Di
Kawasaki disease, Epstein-Barr virus infection, drug eruption.
Investigations\: Measles-speci
Management\: Supportive treatment (rest,
four days post-rash onset, avoid contact with susceptible individuals.
Vaccination\: MMR vaccine (live attenuated) given in two doses at 12 months and 3 years 4 months. E
prophylaxis within 72 hours of exposure.
Complications\: otitis media, pneumonia, tracheobronchitis, convulsions, encephalitis, subacute sclerosing panencephalitis
(SSPE), sight impairment, miscarriage, premature birth, low birthweight, pneumonitis in pregnancy.
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Introduction

Measles, also known as rubeola, is a highly contagious respiratory viral infection. It is a noti
Kingdom.
1
Prior to the introduction of the measles vaccine in 1968, there were around 160,000 to 800,000 reported annual
noti
2
year.
There were 808 con
3
Although measles is more commonly seen in young children, those of any age can contract the disease if they are
unvaccinated or have never been infected before.
4
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Aetiology

Measles is an airborne infection caused by a virus of the family P a r a m y x o v i r i d a e , genus morbillivirus. It is a single-stranded,
spherical RNA virus.
5,6
Measles is spread through respiratory droplets from coughing, sneezing, close personal contact, or direct contact with
1 6
nasal or throat secretions. The virus can remain transmissible for up to two hours after it is spread on surfaces.
The incubation period lasts around 10 days.
5
Once infected, the person is infectious from the onset of symptoms till four days after the rash has appeared.
1
A person who has been infected with measles will develop lifelong immunity.
6

Risk factors

Risk factors for measles include\:
5
Exposure to the measles virus
Lack of prior immunisation against measles
Failure to respond to the vaccine

Clinical features

History

After the incubation period, a prodromal phase follows, after which the rash develops. The prodromal phase lasts 2 - 4
days.
1
Typical symptoms in the prodromal phase include\:
A fever of 39°C or more without antipyretics, decreases after the rash develops
Cough
Conjunctivitis
Coryza
Diarrhoea
Other important areas to cover in the history include\:
Past medical history\: previous infection with measles confers lifelong immunity
Vaccination status

Clinical examination

Typical clinical
1,6
Koplik’s spots\: These are two to three mm wide, small, red spots with blue-white centres seen on the buccal mucosa
(Figure 1). Koplik’s spots are pathognomonic of measles; appearing one to two days before the onset of the rash and may
persist for a further one to two days.
Erythematous, maculopapular rash\: beginning on the face and behind the ears, it spreads downwards towards the
trunk and limbs over three to four days and appears on the hands and feet last (Figure 2). It may become con
spreads. The rash lasts for about
desquamation.
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Figure 1. Koplik’s spots.
7
Figure 2. Skin rash on a patient’s abdomen 3 days after the onset of measles.
8

Di

Consider an alternative diagnosis in those who are immunised, their clinical features are atypical, have a lack of history of
contact with measles, have not travelled to endemic countries, and if there are no local outbreaks.
1
For more information, see the Geeky Medics guide to infectious rashes in paediatrics.
Table 1. Di
1,5,9,10
Di
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Rubella
Parvovirus B19
(erythema infectiosum)
Herpes virus type 6
(roseola infantum)
Streptococcal infection
(e.g. scarlet fever)
Early meningococcal
disease
Kawasaki disease
Typically a mild illness; presents with a
maculopapular rash which spreads in a similar
pattern as measles but is not con
usually resolves in three days.
No Koplik's spots.
Generally, a mild, self-limiting illness that
typically presents with a bright red rash on the
cheeks, followed by a red, lacy rash on the rest of
the body.
No Koplik's spots.
Arthralgia and arthritis may be seen in adults.
Usually, a mild illness which may also be
asymptomatic. A maculopapular rash appears
after fever breaks.
No Koplik's spots.
A sore throat is typically a prominent feature. On
examination, a ‘strawberry tongue’ may be seen.
No cough.
A maculopapular rash develops,
abdomen, after which it spreads to the back and
limbs 12–24 hours following symptom onset.
No Koplik's spots.
A maculopapular rash may be seen, but it
becomes purpuric in later stages. The rash is
non-blanching when a glass is pressed against it.
No Koplik's spots.
Usually diagnosed in children with a fever of 39°C
or more for at least
the following to
echocardiographic evidence of coronary artery
aneurysms)\:
In
pharyngeal mucosa
Erythema, oedema and/or desquamation of
extremities
Bilateral dry conjunctivitis
Polymorphic rash starting on the soles, palms,
and perineum then spreads to the trunk and
extremities
Cervical lymphadenopathy
No Koplik’s spots.
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Ebstein-Barr virus
infection (infectious
mononucleosis)
Drug eruption
Patients present with fever, sore throat, and
lymphadenopathy; pharyngeal exudates, and
hepatosplenomegaly may also be seen.
A non-speci
urticarial, erythema multiforme-like, or
maculopapular) may be seen in those who were
treated with amoxicillin.
No Koplik’s spots.
Typically follows a recent history of medication or
drug ingestion.

Investigations

Consider a diagnosis of measles in those presenting with a fever of 39ºC or more without antipyretics, cough, coryza,
conjunctivitis, and the maculopapular rash.
1
If a diagnosis of measles is suspected, the local health protection team should be noti
using serology is required.
1
A measles-speci
acute infection.
5

Management

Measles is usually a self-limiting condition, its symptoms tend to resolve in about a week.
1
General supportive treatment for measles includes\:
1
Rest
Advice regarding adequate
Antipyretics\: paracetamol/ibuprofen for symptomatic relief
Some patients, depending on severity, may also be given vitamin A.
5
People with suspected measles should not attend school or work for at least four days after the rash has appeared and
should avoid contact with those who are susceptible (unimmunised children and adults, pregnant women, and
immunocompromised individuals).
1

Vaccination

The measles, mumps, and rubella (MMR) vaccine, containing live attenuated strains of the virus, is used to prevent
measles infection. The MMR vaccine is onational immunisation programme and is given in two doses,
the
11
The vaccine may also be given as e
and is o
6
National coverage of MMR1 and MMR2 in children aged
year, lower than the national target of 95%.
12
Of those vaccinated, 95% are protected against measles after MMR1 and 99% after both MMR1 and MMR2.
5

Complications

Complications tend to be more severe in infants, adults, those who are pregnant, immunocompromised, and the
chronically ill or malnourished. Usually, they a
1
Possible complications of measles include\:
1,5,6
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Otitis media
Pneumonia\: occurs either early in the illness with pulmonary involvement of measles or later, as a result of bacterial
superinfection.
Tracheobronchitis
Convulsions
Encephalitis
Subacute sclerosing panencephalitis (SSPE)\: a rare degenerative disease of the CNS, causing seizures and a
motor, cognitive, and behavioural function. Usually seen in children, more commonly boys, who contracted measles at a
very young age. SSPE occurs
Sight impairment\: patients with vitamin A de
Measles infection in pregnancy
Measles acquired in pregnancy can lead to\:
13
Miscarriage or stillbirth
Premature birth
Low birthweight
A potentially fatal pneumonitis can also occur in the mother as a result of measles infection in pregnancy.
6

References

NICE CKS. Measles. Last revised in March 2018. Available from\: [LINK]
UK Health Security Agency. Measles\: the green book, chapter 21. Last updated 31 December 2019. Available from\: [LINK]
UK Health Security Agency. Con
1 February 2022. Available from\: [LINK]
NHS inform. Measles. Last updated\: 29 April 2022. Available from\: [LINK]
BMJ Best Practice. Measles infection. Last updated on 08 Apr 2022. Available from\: [LINK]
Patient.info. Measles. Last edited 30 Sep 2020. Available from\: [LINK]
CDC Public Health Image Library. ID#\: 6111. Licence\: [Public domain]
CDC Public Health Image Library. ID#\: 3168. Licence\: [Public domain]
Patient.info. Kawasaki Disease. Last edited 7 May 2020. Available from\: [LINK]
NICE CKS. Glandular fever (infectious mononucleosis). Last revised in July 2021. Available from\: [LINK]
NHS. MMR (measles, mumps and rubella) vaccine. Last reviewed on 8 April 2020. Available from\: [LINK]
NHS Digital. Childhood Vaccination Coverage Statistics - 2020-21. Published on 30 Sep 2021. Available from\: [LINK]
NHS. Measles. Last reviewed on 21 February 2022. Available from\: [LINK]

Reviewer

Dr Zhivka Chuperkova
Paediatrician, Paediatric Neurologist
Medical University of Varna
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