hot & spotty #2…

the case.

A 14 year old boy is bought to ED with a 4 day history of fevers. His parents are concerned as this rampant red rash has rapidly spread across his body overnight….

TorsoRash#1       TorsoRash#2

He’s had a cough & flu-like symptoms for 2-3 days. His eyes are blood-shot…

[DDET You “spot” something else that gives you the diagnosis ??]

Koplik Spots


[DDET What’s the “spot” diagnosis ?]


The most common vaccine-preventable cause of death among children.


  • A highly contagious, endemic viral infection.
    • Single-stranded RNA paramyxovirus.
  • Peak incidence: Winter to Spring.
    • Transmission via respiratory droplets.
  • Rare in infants < 6-8 months (2* maternal antibodies)
  • Incubation period ~ 10 days (post exposure)
  • Infectious period:
    • 1-2 days before prodrome
    • ~ 4 days after rash appears.

The Vaccine.

  • MMR vaccine. Two-dose schedule.
  • Decreased by 99% since vaccine introduction in the 60’s.
    • > 95% immunity required to prevent epidemics.


  • Prodrome ~ 3-4 days.
    • High fevers & URTI symptoms.
      • “Cough, coryza & conjunctivitis”
    • Associated malaise, photophobia, eyelid oedema & myalgias.
  • Exanthem develops ~ 14 days post-exposure.
    • Centrifugal pattern: central to peripheral.
    • Hairline –> face –> chest –> abdomen –> feet.
    • Reddish-brown, erythematous maculopapular rash –> confluence (morbilliform).
    • May have desquamation during healing phase.
    • Resolves within 6-7 days.
  • Koplik spots (seen above).
    • Pathognomonic exanthem.
    • ~1mm white lesions (with bright red base) on buccal mucosa, opposite lower molars.
    • Present 1-2 days prior to rash.


[DDET Differential Diagnoses to consider…]

  • Rubella
  • Scarlet Fever
  • Enterovirus
  • Roseola
  • Erythema Infectiosum (“slapped cheek”)
  • Kawasaki disease


[DDET Confirming the diagnosis…]

  • Measles IgM.
    • If positive –> confirms disease.
    • Detectable for ~ 1 month after rash onset.
  • Viral culture.
    • from nasopharynx, blood or urine.


[DDET What potential complications should we look out for?]

Meningoencephalitis / Encephalomyelitis.

  • 1:1000 cases.
  • 40% die or have severe neurologic injury.
  • Symptoms:
    • Ataxia, agitation, vomiting & seizures.

Subacute sclerosing panencephalitis.

  • a progressive neurodegenerative disorder
  • behavioural disturbance, myoclonus, seizures, pyramidal signs…
  • Thankfully RARE.
    • ~5:100,000 cases.
  • 2-10 years after measles infection.
  • Fatal in 1-3 years.


  • Leukopenia
    • < 2000 is a marker of poor prognosis
  • Thrombocytopenia
  • Jaundice (rare)
  • Bronchiolitis
  • Pneumonia (+ giant cell pneumonia)
  • Croup
  • Cervical adenitis
  • Myopericarditis


[DDET Management.]

  • Supportive care.
  • Vitamin A.
    • Increased morbidity/mortality with Vitamin A deficiency
    • Consider in children 6-24 months (needing admission).


[DDET More information for health care workers…]

  • Isolate all suspected cases as soon as they are identified
  • Maintain standard & airborne precautions.
  • If staff have no prior immunity, vaccine provides permanent protection & may prevent disease if given within 72 hours of exposure.
    • 0.25mL/kg (max 15mL)
    • Preferable to IG (which can be given up to 6 days post-exposure), as this immunity is temporary.
  • All suspected cases MUST be reports to Public Health for contact tracing etc.


[DDET What about the pregnant Auntie ??]

“Do we need to keep the kids away from her ?” Mum asks…

The short answer is YES !!

Risk to Pregnant Females.

  • Exposure can lead to miscarriage, premature labour or stillbirth.
  • Consider use of measles immunoglobulin.
    • Does not prevent complications, but may attenuate disease severity.
  • Do NOT have MMR vaccine if you are already pregnant.

If in doubt, the auntie should see her GP as soon as possible.


[DDET References.]

  1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  2. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition.
  3. PEMsoft “Measles (Rubeola)” via CIAP


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