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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 130-132

Infant viral exanthem: Simple sneezes or measles?


1 Department of Pediatrics, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Department of Community Medicine, Government Medical College, Idukki, Kerala, India
3 Department of Pediatrics and Neonatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Submission09-Mar-2020
Date of Acceptance17-Mar-2020
Date of Web Publication09-Oct-2020

Correspondence Address:
Dr. Bharat Pillai
Department of Pediatrics, Amrita Institute of Medical Sciences, 4C, Vijaya Glimpses Apartments, Jawahar Nagar, Kadavanthra, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_22_20

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  Abstract 


Measles is a highly infectious viral exanthema very rarely seen in children under 9 months, as well as adults. We describe a case of measles in a 29-day old infant who presented with fever, rash and pneumonia. Treatment commenced with IV antibiotics, IVIG and oral Vitamin A following admission to the ICU. The mother had a similar illness prior to the onset of symptoms in the baby. She had not received MCV as per schedule. The infant and mother recovered fully without any complications. We conclude that administering one dose of MCV to a woman who has not taken at least two doses of MCV- at least three months prior to conception may help in preventing measles in the infant in first nine months of life.

Keywords: Immunization, infant measles, vaccination failure


How to cite this article:
Pillai B, Jayakumar C, Ramakrishnan D, Vishwanath J. Infant viral exanthem: Simple sneezes or measles?. Amrita J Med 2020;16:130-2

How to cite this URL:
Pillai B, Jayakumar C, Ramakrishnan D, Vishwanath J. Infant viral exanthem: Simple sneezes or measles?. Amrita J Med [serial online] 2020 [cited 2020 Oct 30];16:130-2. Available from: https://www.ajmonline.org.in/text.asp?2020/16/3/130/297554




  Introduction Top


Measles is a highly infectious acute viral disease commonly seen in the pediatric age group. Although usually abortive, it can be severe due to subsequent complications.[1] Vaccination is highly effective at preventing infection. Infants <9 months of age are usually immune to infection due to persistent maternal antibodies. Failure of vaccination in the mother may predispose babies to infection.


  Case Report Top


A 47-day-old male child presented with a history of fever and cough for 3 days, followed by generalized maculopapular rash and purulent discharge from both eyes of a 2-day duration. Rash initially started behind the ears and progressed to the face, chest, and then to the abdomen and back.

The baby with a birth weight of 2.6 kg was immunized at birth. On the twenty-ninth day, baby developed fever, grunting, poor feeding and was diagnosed to have pneumonia, which was then treated with intravenous Cefotaxime and Amikacin- later changed to Clarithromycin.

A 29-year-old mother had a high-grade fever, erythematous maculopapular rash highly suggestive of measles [Figure 1] with oral ulcers, and purulent conjunctival congestion 7 days before the illness of the baby. Cough with an intensely pruritic rash with branny desquamation confirmed the clinical diagnosis of measles. She had only been vaccinated with one dose of measles vaccine at 9 months of age but had not taken any further doses of measles-containing vaccine (MCV).
Figure 1: Erythematous maculopapular rash seen in the mother

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The infant was irritable and febrile at presentation, with stable vitals. Erythematous maculopapular rash was noted, extending from the head to the trunk, including the groin and buttocks but sparing the palms and soles [Figure 2] and [Figure 3]. Koplik's spots were seen bilaterally. Purulent discharge was noted from both eyes. Scattered crackles were heard in all lung fields bilaterally. Examination of other systems showed no abnormal findings.
Figure 2: Erythematous maculopapular rash seen on the face and trunk of the infant with desquamation around the forehead and eyes

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Figure 3: Rash seen on the back extending onto the buttocks

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The child was admitted to the isolation intensive care unit with a provisional diagnosis of measles with pneumonia. Chest X-ray (CXR) was normal at admission. Intravenous cefotaxime and amikacin were started due to crackles heard on auscultation. Blood cultures yielded no growth. Due to the deterioration of mental status and irritability, intravenous immunoglobulin (IVIG) was started at 400 mg/kg as passive immunization. Cerebrospinal fluid (CSF) study showed elevated protein count with lymphocytosis. Gram stain and cultures of CSF were negative. A repeat CXR showed bilateral patchy infiltrates along the hilar and basal zones. Based on this, antibiotics were continued with an addition of 50,000 U of oral Vitamin A. On day 4 of illness, the baby recovered uneventfully and was shifted to the ward. He was discharged on oral antibiotics.


  Discussion Top


In India, there were a reported 92,000 cases of measles in 2005 in children under 5 years.[2] This is overwhelming considering that measles is a vaccine-preventable disease. The reported mortality rate was a staggering 3.3%, with girls being more severely affected than boys.[2] Humans are the only reservoir of measles virus,[3] which suggests that the virus could be eradicated.[4] Clustering of cases was seen in districts with poor execution of vaccination programs.[5]

Most deaths occur due to associated complications, including lower respiratory tract infection (especially staphylococcal pneumonia), secondary tuberculosis, dehydration, and skin infections.[1] Immunocompromised and unvaccinated children comprise the majority of the at-risk population.[6] Herd immunity confers some protection to this subset. A rising trend of nonvaccinators have been identified to be at risk of developing the disease[7] and transmitting it, potentially disrupting the herd immunity.

In India, the current National Immunization Schedule advises the first dose of MCV at 9 months of age.[8] This is due to persistent maternal antibodies in the infant till 9 months of age. It is followed up by a second dose of MCV after 6 months or an optional measles, mumps, and rubella combined vaccine (MMR) at 15 months. The development of infection in our case might have been due to the mother not taking a second dose of MCV. Improper vaccine logistics or faulty vaccine administration could also have been the cause. A mutation in viral strain should also be considered.[9]

Theoretically, seroconfirmation of measles infection is ideal whenever a viral exanthem of fever with rash is suspected. However, affordability plays a vital role in health-care utilization in developing countries such as India. Immunoglobulin M (IgM) or IgG measles was not done in our case since it was not financially feasible and would not have altered the management plan in anyway. According to the WHO, any fever with maculopapular rash with either cough, coryza, or conjunctivitis in children should be considered as measles and treated accordingly.[10]

Three-dose vaccination schedule with MCV at 9 months, 15 months, and at 4½ years; proper vaccine logistics; and appropriate vaccination techniques would be ideal in conferring active immunity against measles. We suggest that if a woman has not taken at least two doses of MCV, giving her one dose of any MCV at least 3 months before conception may help in preventing measles in the infant during the first 9 months of life.


  Conclusion Top


The diagnosis of measles still remains largely clinical, and it is not essential to have laboratory evidence before starting treatment. According to the WHO guidelines, any fever with maculopapular (nonvesicular) rash with either of cough, coryza, or conjunctivitis in children should be considered to be measles and treated accordingly.[10] However, serological confirmation should be obtained should any uncertainty in diagnosis arise.

Early initiation of treatment is key in preventing complications associated with measles. Although not indicated, we have seen that it is prudent to observe the progression of the disease under a broad-spectrum antibiotic cover. The mental status of the child should be closely monitored for early recognition of central nervous system involvement. IVIG is an effective treatment modality for passive immunization if measles-specific IVIG is not available.

Proper handling of vaccines and appropriate immunization techniques is vital in conferring active antibody-mediated immunity against measles. Vaccine failure despite having completed the full schedule is known in literature, and such cases should be followed up and immunized. We also suggest active patient education, and encourage the consumption of foods rich in Vitamin A.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mishra A, Mishra S, Jain P, Bhadoriya RS, Mishra R, Lahariya C. Measles related complications and the role of Vitamin A supplementation. Indian J Pediatr 2008;75:887-90.  Back to cited text no. 1
    
2.
Vaidya SR. Commitment of measles elimination by 2020: Challenges in India. Indian Pediatr 2015;52:103-6.  Back to cited text no. 2
    
3.
Rota PA, Moss WJ, Takeda M, de Swart RL, Thompson KM, Goodson JL. Measles. Nat Rev Dis Primers 2016;2:16049.  Back to cited text no. 3
    
4.
Moss WJ, Strebel P. Biological feasibility of measles eradication. J Infect Dis 2011;204 Suppl 1:S47-53.  Back to cited text no. 4
    
5.
Sudfeld CR, Halsey NA. Measles case fatality ratio in India a review of community based studies. Indian Pediatr 2009;46:983-9.  Back to cited text no. 5
    
6.
Kaplan LJ, Daum RS, Smaron M, McCarthy CA. Severe measles in immunocompromised patients. JAMA 1992;267:1237-41.  Back to cited text no. 6
    
7.
Hopkins Tanne J. Measles: Two US outbreaks are blamed on low vaccination rates. BMJ 2019;364:l312.  Back to cited text no. 7
    
8.
Guidelines for vaccinations of a normal child in India, Indian J Nephrol. 2016;26(Suppl 1):S5–S6.  Back to cited text no. 8
    
9.
Schrag SJ, Rota PA, Bellini WJ. Spontaneous mutation rate of measles virus: Direct estimation based on mutations conferring monoclonal antibody resistance. J Virol 1999;73:51-4.  Back to cited text no. 9
    
10.
WHO | WHO Guidelines for Epidemic Preparedness and Response to Measles Outbreaks. Available from: https://www.who.int/csr/resources/publications/measles/whocdscsrisr991.pdf?ua=1. [Last accessed on 2019 Feb 25].  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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