Clinical Background
Measles is a highly contagious disease caused by the measles (rubeola) virus.
Epidemiology
- Prevalence – minimal number of cases yearly in U.S. due to the high rate of vaccination
- >750,000 deaths worldwide
- Occasional small outbreaks from imported cases of measles primarily infecting unvaccinated individuals
- Transmission
- Via respiratory droplets
- Highly contagious; >90% transmission among non-immune individuals
Organism
- A single-stranded RNA virus and the only member of genus Morbillivirus (Paramyxoviridae family)
- Humans are the only natural reservoirs
Clinical Presentation
- Highly contagious, acute, exanthematous respiratory disease with pathognomonic Koplik spots on the buccal mucosa
- Cutaneous rash starts centrally and spreads to the periphery
- Diagnosis based on clinical exam may be difficult, especially in atypical cases
- In atypical measles, rash begins peripherally and moves centrally
- Atypical measles has occurred in patients who received killed vaccines and later came in contact with wild virus strain
- Severe, often fatal pneumonia can occur in patients with deficient cell-mediated immunity
- Complications
- Pulmonary – primary giant cell pneumonia (Hecht pneumonia)
- Severe, often fatal pneumonia can occur in patients with deficient cell-mediated immunity
- Neurological – coma, seizures, encephalitis
- Subacute sclerosing panencephalitis (SSPE) – rare, progressive encephalitis that may result in dementia and death
- Acute disseminated encephalomyelitis (ADEM)
- Measles inclusion body encephalitis in immunocompromised patients
- Gastrointestinal – disease mimicking appendicitis
- Cardiovascular – myocarditis, pericarditis
- Occular – corneal ulceration and scaring
- Gestational – increased incidence of pneumonia in pregnant women, spontaneous abortion, premature delivery and low birth weight babies
Treatment
- Treatment of measles is largely symptomatic
- Vitamin A shown to be effective (American Academy of Pediatrics)
- Treat any secondary infections
Prevention
- Prevention includes measles, mumps and rubella (MMR) vaccine administered to 12-15 month old children, with revaccination between 4-12 years
- High fever and pulmonary infiltrates can occur in patients exposed to measles that were vaccinated with MMR between 1964-67
- Symptoms believed to be hypersensitivity reactions to the vaccine
- Mass U.S. immunization has greatly reduced measles infections
- However, some individuals may be susceptible to measles due to vaccine failure or non-immunization
- Because vaccine is live, attenuated virus, do not use in pregnant patients or those with significant immunosuppression
Diagnosis
- Indications for testing
- Suspicious rash and clinical syndrome
- Known exposure to measles by an unvaccinated person
- Confirmation of immunity to measles after vaccination
- Laboratory testing
- Serum testing for antibodies
- Confirm acute infection with measles using IgM and IgG serial testing
- Confirm seroconversion after vaccination using IgG testing
- IgM, IgG cerebrospinal fluid (CSF) testing to identify SSPE (which may occur years after original infection using IgG testing)
- Viral culture
- Nasopharyngeal and blood cultures are most sensitive if collected during prodrome up to 1-2 days after onset of rash
- Virus can be isolated from urine culture up to 1 week or more after onset of rash
- Difficult to isolate from CSF and brain tissue
- RT-PCR – not widely available, but useful for testing CSF
Differential Diagnosis
- Rubella
- Enterovirus
- Parvovirus B19
- Arboviruses
- Scarlet fever
- Kawasaki disease
- Dengue fever
- HIV
- Secondary syphilis
- Drug eruptions
- HHV-6/HHV-7
Pharmacogenetics and Therapeutic Drug Monitoring
Indications for Laboratory Testing
- Tests generally appear in the order most useful for common clinical situations
- Click on number for test-specific information in the ARUP Laboratory Test Directory
| Test Name and Number |
Recommended Use |
Limitations |
Follow Up |
| Measles (Rubeola) Antibodies, IgG & IgM 0050375 Method: Enzyme-Linked Immunosorbent Assay |
Diagnose measles
|
Low IgM antibody levels occasionally persist >12 months post-infection or immunization |
Residual IgM response may be distinguished from early IgM response by testing patient sera 2-3 weeks later for changes in specific IgM antibody levels
|
| Measles (Rubeola) Virus Culture 0065055 Method: Cell Culture/Immunofluorescence |
Gold standard test for nasopharyngeal aspirate/washing, throat swab, lung tissue, CSF or urine samples
|
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| Measles (Rubeola) Antibody, IgG 0050380 Method: Enzyme-Linked Immunosorbent Assay |
Screen for vaccination
|
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| Measles (Rubeola) Antibody, IgM, CSF 0054441 Method: Enzyme-Linked Immunosorbent Assay |
Diagnose rare but fatal subacute sclerosing panencephalitis (SSPE) in CSF samples
|
Rubeola CSF antibody detection may indicate central nervous system infection; however, consider possible contamination by blood or transfer of serum antibodies across blood-brain barrier |
|
| Measles (Rubeola) Antibody, IgG, CSF 0054440 Method: Enzyme-Linked Immunosorbent Assay |
Diagnose rare but fatal subacute sclerosing panencephalitis (SSPE) in CSF samples |
Rubeola CSF antibody detection may indicate central nervous system infection; however, consider possible contamination by blood or transfer of serum antibodies across blood-brain barrier |
|
Additional Tests Available
Click the plus sign to expand the table of additional tests.
| Test Name and Number | Comments |
| Measles (Rubeola) Antibody, IgM 0099597 Method: Enzyme-Linked Immunosorbent Assay |
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| Encephalitis Panel, CSF with Reflex to HSV Type 1 & 2 Glycoprotein G-Specific Ab, IgG 2001741 Method: Enzyme-Linked Immunosorbent Assay/Indirect Fluorescent Antibody |
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| Encephalitis Panel, Serum with Reflex to HSV Type 1 and Type 2 Glycoprotein G-Specific Ab, IgG 2001742 Method: Enzyme-Linked Immunosorbent Assay/Indirect Fluorescent Antibody |
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| Meningoencephalitis Panel, CSF with Reflex to HSV Type 1 & Type 2 Glycoprotein G-Specific Ab, IgG 2001765 Method: Enzyme-Linked Immunosorbent Assay/Indirect Fluorescent Antibody |
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| Meningoencephalitis Panel, Serum with Reflex to HSV Type 1 & Type 2 Glycoprotein G-Specific Ab, IgG 2001764 Method: Enzyme-Linked Immunosorbent Assay/Indirect Fluorescent Antibody/Chemiluminescent Immunoassay |
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Guidelines
General References
American Academy of Pediatrics. Measles. In Pickering LK, ed. Red Book: 2006 Report of the Committee on Infectious Diseases, 26 ed. Elk Grove Village, IL: American Academy of Pediatrics, 2006. pp. 441-452.
Oxman MN. Measles Virus. In Richman DD, Whitley RJ, Hayden FG, eds. Clinical Virology, 2nd ed. Washington, DC: ASM Press, 2002. pp. 791-828.
Comprehensive Review: July 2009
Last Update: August 2009