MEASLES, COMPLICATIONS AND POST DEBILITY.pptx

An overview of measles, its complications and post debility sequelae

1. MEASLES, COMPLICATIONS AND POST DEBILITY Presenter: Dr. Valentina Daniel Supervising SR: Dr. Esuola Supervising Consultant: Dr. Ekere

2. OUTLINE 1. Introduction 2. Epidemiology 3. Pathophysiology 4. Clinical Features 5. Investigations 6. Complications 7. Differential Diagnoses 8. Treatment 9. Post Measles Debility 10. Prevention 11. References

3. INTRODUCTION Measles is a highly contagious viral disease caused by Morbillivirus , a member of the Paramyxovirus family, which is transmitted to a susceptible individual through aerosol or by direct contact. The virus infects the mucous membranes of an exposed individual and then spreads to other parts of the body. Measles is known to infect only humans with no known animal reservoir.

4. Measles has an incubation period of about 10 days (with a range of 7 to 18 days). It is characterized by prodromal fever, conjunctivitis, coryza , cough and presence of Koplik spots The mortality rate for measles infection in children is usually 0.2%, but may be up to 10% in malnourished children. In cases with complications, the mortality rate may rise to 20-30%

5. EPIDEMIOLOGY Measles is an acute and extremely contagious viral disease that has caused approximately 2.6 million deaths before the introduction of the vaccine. Measles affects up to 20 million people a year worldwide, most of these infections are seen in the developing areas of Africa and Asia

6. E pidemiology Globally, measles mortality fell 60% from an estimated 873,000 deaths in 1999 to 345,000 in 2005 In Africa, measles remains a leading cause of death and disability in most countries In 2015, the World Health Organization (WHO) estimated that of the 134,200 measles deaths recorded, majority were in sub-Saharan Africa .

7. Epidemiology The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) reported recently that from February to May 2023, measles outbreaks attributed to the continuous influx of unvaccinated children from hard-to-reach and extremely hard-to-reach areas in north-east Nigeria claimed the lives of more than 50 children .

8. E pidemiology Borno State was the most affected, recording over 5,000 suspected cases, with Jere LGA and Maiduguri Metropolitan Council recording 1,644 and 1,627 cases, respectively, by the end of May 2023. There were 917 suspected cases of measles in Yobe State, with 9 deaths from measles-related complications, and 66 suspected cases of measles reported in Adamawa State

9. Pathophysiology Measles is a systemic infection. The primary site of infection is alveolar macrophages or dendritic cells. Two to three days after replication in the lung, measles virus spreads to regional lymphoid tissues followed by a systemic infection.

10. Pathophysiology Following further viral replication in regional and distal reticuloendothelial sites, a second viremia occurs 5 to 7 days after initial infection. During this phase, infected lymphocytes and dendritic cells migrate into the sub-epithelial cell layer and transmit measles to epithelial cells. Following amplification in the epithelia, the virus is released into the respiratory tract

11. Clinical Features The clinical picture of measles can be divided into three stages: prodromal eruptive convalescent

12. KOPLIK SPOTS

13. Clinical features The primary or prodromal phase lasts 4-6 days and is characterized by the presence of high fever, malaise, coryza, conjunctivitis, palpebral edema, and dry cough. Most cases show the characteristic Koplik spots of the disease, located in the buccal mucosa at the height of the second molar, and appear two to three days before the rash and disappear on the third day.

14. The second phase, the eruptive stage, is characterized by the appearance of a maculo-papular rash, initially fine that subsequently becomes confluent. The rash begins behind the auricle and along the hair implantation line, and extends downward to the face, trunk, and extremities.

15. The third phase or convalescence occurs after three to four days when the rash begins to disappear, in the same order in which it appeared, leaving brown spots and producing a thin peeling of the skin. The fever disappears two to three days after the rash begins, as does the general malaise .

16. In atypical measles, the onset is acute, with high fever, headache, abdominal pain, and myalgia. The rash may be minimal in children with measles modified by the vaccine. In addition, they may not have one or more of the classic triad - cough, coryza , or conjunctivitis. Unusual manifestations of measles include pneumonia, otitis media, myocarditis, pericarditis, and encephalitis.

17. Investigations Serological tests with specific immunoglobulin G ( IgG ) and immunoglobulin M ( IgM ) measurements, molecular biologic techniques with reverse transcription-polymerase chain reaction application, and viral isolation are available for diagnostic confirmation. The measles specific IgM antibody in primary infection, which is confirmatory of disease, are detected from the third day of the rash and remain positive for 30 to 60 days.

18. Investigations For the evaluation of IgG , there is more than a four-fold increase in antibodies between the acute and convalescence phases of the disease. Measles RNA can be detected by a polymerase chain reaction from pharyngeal or nasopharyngeal swabs or urine samples. This test confirms the disease and allows the genotyping of the agent.

19. C omplications Bacterial super-infection, including pneumonia Acute thrombocytopenic purpura Encephalitis Transient hepatitis Subacute sclerosing panencephalitis

20. Differential diagnoses rubella, scarlet fever, drug rash, serum sickness , roseola infantum , infectious mononucleosis, erythema infectiosum , Kawasaki disease

21. Differential diagnoses Rubella causes a rash similar to measles with head to caudal distribution, mild respiratory symptoms, the absence of conjunctivitis. Still, it is accompanied by the presence of adenopathies - which is characteristic of this disease. Roseola is characterized by an illness beginning with a high fever, which subsides after a few days, accompanied by the appearance of a rash in the central part of the body, without the presence of Koplik's points.

22. Differential diagnoses Mononucleosis is a febrile viral disease, a characteristic course with few symptoms during childhood, contrary to what happens in more advanced ages. Mononucleosis manifests itself by pharyngeal compromise, polyadenopathy , and hepatosplenomegaly , and the rash can have different forms of presentation. In Kawasaki disease, there is an ocular compromise with the presence of conjunctivitis without exudate, and the respiratory compromise is not part of this pathology.

23. Differential diagnoses Group A Streptococcus (particularly Scarlet fever) may present with a similar rash (a coarse, sandpaper-like, blanching, erythematous) to measles in association with pharyngitis. Drug rash: A rash caused by drug hypersensitivity often resembles the measles rash, but a prodrome is absent, there is no cephalocaudal progression or cough, and there is usually a history of recent drug exposure.

24. TREATMENT There is no specific treatment of measles except supportive care to relieve common symptoms associated with this condition. Supportive measures include antipyretics for fevers, hydration, and adequate nutritional support, including the encouragement of breastfeeding.

25. The World Health Organization recommends the administration of vitamin A for all children with measles, but particularly for children who reside in areas where the case fatality rate is more than 1%, areas with known vitamin A deficiency, and in severe cases of complicated measles.

26. For infants less than 6 months of age, the doses are 50,000 IU for children between 6 and 12 months, 100,000 IU; for children aged 12 months and older, 200,000 IU. The measles virus is susceptible to the medication ribavirin in vitro, but due to a lack of clinical data, its routine use is not recommended. It may be considered for use in certain high-risk groups.

27. POST MEASLES DEBILITY Subacute sclerosing panencephalitis (SSPE) is a very rare, but fatal disease of the central nervous system that results from a measles virus infection acquired earlier in life. SSPE generally develops 7 to 10 years after a person has measles, even though the person seems to have fully recovered from the illness. The risk of developing SSPE may be higher for a person who gets measles before they are 2 years of age.

28. Subacute sclerosing panencephalitis is characterized by progressive cognitive decline. Symptoms typically present about 8 to 11 years of post-measles infection. Initially, personality or behavior changes are present, in addition to poor school performance and intellectual deterioration.

29. There is a steady decline in motor function with myoclonus in most cases, autonomic dysfunction, and focal paralysis . Some patients have seizures, either focal or generalized, and about one-third of patients with SSPE develop epilepsy. Patients eventually fall into a vegetative state or akinetic mutism, which is shortly followed by death

30. The course of SSPE has been divided into stages, each of which describes a certain phase of the disease. Stage I includes many personality or behavioral changes, such as irritability, dementia, lethargy, social withdrawal, or speech regression. Stage II is made up of the progressive decline in motor function, including myoclonus, dyskinesia, and dystonia.

31. Stage III consists of patients who have progressed to extrapyramidal symptoms, posturing, and spasticity . Stage IV occurs when patients develop akinetic mutism, autonomic failure, or enter a vegetative state .

32. DIAGNOSIS OF SSPE Serologic testing Electroencephalography (EEG) Neuroimaging (CT or MRI) SSPE is suspected in young patients with dementia and neuromuscular irritability. EEG shows periodic complexes with high-voltage diphasic waves occurring synchronously throughout the recording.

33. CT or MRI may show cortical atrophy or white matter lesions. CSF examination usually reveals normal pressure, cell count, and total protein content; however, CSF globulin is almost always elevated, constituting up to 20 to 60% of CSF protein. Serum and CSF contain elevated levels of measles virus antibodies.

34. Anti-measles IgG appears to increase as the disease progresses . If test results are inconclusive, brain biopsy may be needed.

35. Treatment of SSPE Supportive care Anticonvulsants and other supportive measures are the only accepted treatments. Isoprinosine, interferon alfa, and  lamivudine are controversial, and antiviral medications have generally not proved helpful

36. Prognosis for SSPE The disease is almost invariably fatal within 1 to 3 years (often pneumonia is the terminal event), although some patients have a more protracted course.

37. Prevention Vaccine Vaccination against measles is the most effective and safe prevention strategy Measles vaccine is available as a combined vaccine with measles-mumps-rubella vaccine Post-exposure Prophylaxis Susceptible individuals exposed to measles may be protected from infection by either vaccine administration or with Ig The vaccine is effective in prevention or modification of measles if given within 72 hr of exposure Ig may be given up to 6 days after exposure to prevent or modify infection

38. Prevention strategies Primary – Vaccination. Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. Secondary :- Secondary prevention includes steps to isolate cases and treat or immunize contacts so as to prevent further cases of meningitis or measles, for example, in outbreaks.

39. Tertiary Prevention : It is implemented in symptomatic patients and aims to reduce the severity of the disease as well as of any associated sequelae. While secondary prevention seeks to prevent the onset of illness, tertiary prevention aims to reduce the effects of the disease once established in an individual.

40. Quaternary prevention Public health interventions to reduce the secondary spread of measles are:- vaccination of susceptible contacts; human immunoglobulin (Ig) for susceptible contacts; quarantine of susceptible contacts; isolation of active measles cases; and special vaccination clinics or activities during outbreaks to increase population immunization coverage

41. Conclusion Measles is a highly contagious viral infection spread by air/droplet transmission There are several symptoms but it is characterized by a distinctive rash. Measles can be prevented by vaccination, either singly or in addition to mumps and rubella, all of which can also have serious complications. High vaccination coverage provides a ‘herd immunity’ effect which also protects those who are unable to be vaccinated

42. Thank you for listening

43. references