• Clinical science

Measles (Rubeola)

Summary

Measles (Rubeola) is a highly infectious disease that is caused by the measles virus. There are two phases of disease: a catarrhal (prodromal) stage and an exanthem stage. The catarrhal stage is characterized by a fever with conjunctivitis, coryza, cough, and pathognomonic Koplik spots on the buccal mucosa. The sudden development of a high fever, malaise, and exanthem represents the next phase. The exanthem stage is typically characterized by an erythematous maculopapular rash that originates behind the ears and spreads to the rest of the body towards the feet. Infection is usually self-limiting and followed by lifelong immunity. Disease management includes vitamin A supplementation, symptomatic treatment, and possible post-exposure prophylaxis (PEP). Measles causes transient immunosuppression and may lead to serious complications such as encephalitis, otitis, or pneumonia. A rare but lethal late complication of measles is subacute sclerosing panencephalitis (SSPE), which may also affect immunocompetent individuals. Active immunization against measles is available in form of a combination vaccine against mumps and rubella (MMR). The first dose is recommended between the ages of 12 and 15 months and the second dose between 4 and 6 years of age or at least 28 days after the first dose. The prognosis is good in uncomplicated cases. However, newborns and immunocompromised patients are more likely to suffer from severe complications.

Epidemiology

  • Distribution: Measles typically occurs in regions with low vaccination rates and in resource-limited countries. [1]
  • Peak incidence: < 12 months of age [1]
  • Infectivity [1]
    • ∼ 90%
    • Highly contagious 4 days before and up to 4 days after the onset of exanthem.

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Clinical features

Incubation period

  • Duration: ∼ 2 weeks after infection

Prodromal stage (catarrhal stage) [2]

Exanthem stage [2]

  • Duration: ∼ 7 days (develops 1–2 days after enanthem)
  • Presentation
    • High fever, malaise
    • Generalized lymphadenopathy
    • Erythematous maculopapular, blanching, partially confluent exanthem
      • Begins behind the ears along the hairline
      • Disseminates to the rest of the body towards the feet (palm and sole involvement is rare)
      • Fades after ∼ 5 days of onset, leaving a brown discoloration and desquamation in severely affected areas

Recovery stage

The cough may persist for another week and may be the last remaining symptom.

The most important findings of measles are the 3 Cs and 1 K: Coryza, Cough, Conjunctivitis, and Koplik spots.

Diagnostics

Measles should be suspected in a patient with typical clinical findings. Laboratory tests are always necessary to confirm the diagnosis. [3]

Differential diagnoses

Differential diagnoses of infectious pediatric conditions
Appearance of exanthem Course of exanthem Other clinical features
Measles
  • Begins on the face, frequently behind the ears
  • Disseminates to the rest of the body
  • Fades after ∼ 5 days with brown discoloration and desquamation
Scarlet fever
  • Begins in the neck region
  • Disseminates to the head, trunk, and extremities
  • Brown discoloration and desquamation of the skin during the second to fourth week of infection
Rubella
  • Begins behind the ears
  • Extends to the trunk and extremities
  • Symptoms usually disappear within 3 days
Fifth disease (erythema infectiosum)
  • Maculopapular
  • Initially confluent
  • Lace-like and reticular appearance over time
  • Becomes more pronounced after exposure to sunlight or heat
  • “Slapped cheek” appearance: flushed cheeks with perioral pallor
  • Spreads to extremities and trunk in 50% of cases
  • Fades after ∼ 5–8 days
  • May be recurrent for several months following the initial infection
  • Good general condition
  • Arthritis
Roseola infantum (exanthem subitum)
  • Develops as the fever subsides
  • Originates on the trunk and may spread to face and extremities
  • Frequently observed from only several hours to a maximum of 3 days

Chickenpox (Varicella)

  • Vesicular rash on erythematous background
  • Starry sky”: simultaneous occurrence of different stages (e.g., vesicles, crusted papules)
  • Begins on trunk, scalp, face and proximal limbs
  • Involves hands, feet and mucous membranes
  • Severe pruritus
  • Fades after ∼ 1 week
  • Prodrome possible (1–2 days prior to exanthem onset)
  • Oropharyngeal and urogenital ulcers
Hand, foot, and mouth disease
  • Affects feet and hands
  • Rarely generalizes
  • Fades after ∼ 4 days
  • Poor general condition
  • Highly contagious
  • Stomatitis and enanthem
  • Fever

Drug reactions should always be considered as potential cause for a rash.

The differential diagnoses listed here are not exhaustive.

Treatment

  • Symptomatic treatment [4]
  • Vitamin A supplementation reduces morbidity and mortality (especially in malnurished children). [5]
  • PEP in patients without prior vaccination (see “Prevention” below)

Complications

Subacute sclerosing panencephalitis (SSPE) [6][1][7]

Other complications [6][1]

Complications are likely to occur when the fever does not subside after a few days after onset of the exanthem.

We list the most important complications. The selection is not exhaustive.

Prognosis

  • The prognosis of measles infection is good in uncomplicated cases.
  • Fatal courses are more likely in newborns and immunocompromised patients.
  • High fatality rate in resource-limited countries due to secondary bacterial infections.

Prevention

Immunization [1][3]

Primary immunization

Postexposure prophylaxis (PEP)

Reporting regulations [1][3]