measles_pokhra - Measles and Neonatal Tetanus: Measles and...

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Unformatted text preview: Measles and Neonatal Tetanus: Measles and Neonatal Tetanus: Clinical Signs and Treatment Clinical Signs and Treatment Clinical Clinical Prof. Pushpa Raj Sharma Institute of Medicine Kathmandu Kathmandu Measles Case definition Measles Laboratory confirmation in the absence of Laboratory recent immunization (1-14 days) with measles containing vaccine: measles – Detection of measles virus from urine or Detection throat/nasopharyngeal swabs or or – Significant rise in the measles antibody titre Significant between acute and convalescent sera or or – Positive serologic test for measles IgM Positive antibody using a recommended assay. antibody Measles: Basic Characteristics Measles: Also known as “dadura”/”bhosa kai” / rubeola / Also fourth day disease/ first fever fourth Acute viral illness Primarily affects children Highly contagious Paramyxovirus – RNA, single stranded Vaccine preventable – Potential to be eliminated Measles: Signs and Symptoms Measles: Incubation period: 10-12 days (8-16 range) Prodrome – Cough NP, worsens over 4 days, then improves Lasts through entire illness (7-10 days) – Conjunctivitis (purulent), coryza May include photophobia Lasts 6-8 days – Fever: 38-40o C: subsides after 1 week – Diarrhea Chronic, serious if previously malnourished Measles: Signs and Symptoms Symptoms Koplik’s spots – – – – – Part of prodrome: day 1-3 before rash Raised papules on buccal mucosa and conjunctiva Usually adjacent to molars Often white on red base Disappear about time rash occurs Measles: Signs and Symptoms Measles: Rash Hairline Behind Ears Erythematous papular Erythematous eruption eruption Face Travels inferior over 2-3 Travels days days Trunk Coalesces into macular Coalesces “splotches” “splotches” Limbs Often desquamates at end Often of illness of Measles: Signs and Symptoms Measles: Peak of Illness – 2-4 days after onset of rash Other signs and symptoms – Anorexia, malaise, hemorrhagic, Resolution – Rapid improvement at end of febrile period (1 Rapid week) week) – Complete recovery in 10-14 days Summary: Diagnosis / Clinical Summary: Clinical illness includes all of Clinical the following symptoms: the – Temperature of 38.3°C or °C more. more. – Cough, coryza or conjunctivitis – Generalized maculopapular Generalized rash for at least three days following temperature and cough, coryza or conjunctivitis. cough, Koplik’s spots can be classic, Koplik’s but easily missed but Dengue Measles Enteroviruses Rubella Kawasaki Maculopapular Rash with Fever Scarlet Fever Echoviruses Reoviruses Roseola Infantum Mononucleosis Six Case Studies Low grade fever, headache and mild URI symptoms Erythematous facial flushing. “Slapped cheek appeaarence High fever for three days. Developed generalized seizure on the third day. No specific localizing signs. Investigations including LP normal Developed rash on the fourth day after the fever subsided. Rash first appeared on trunk sparing palm and sole Presented with Jaundice and drowsiness, ascitis Started ampicillin Developed rash on 4th day. Bilateral periorbital edema not associatedwith generalized edema Maculopapular rash Fever and rash for three day Forehead and cheeks flushed Non itchy, maculo-papular, punctate, granular generalized, first noticed over neck. Mild fever and cough for two days Developed rash on the second day of fever which appeared on face first and spread allover in one day. Fever: 99.2 axillary; enanthem on the soft palate; tender discrete lymph nodes over retro auricular, sub occipital and posterior cervical region. Rash cleared on third day. Exanthem a common clilnical manifiestation Nonspecific febrile illness (no coryza and conjunctivitis) Rubeolliform rash Rash and fever same time Rash last 3-5 days Case history: Case Five years , child Five – moderate fever, a hacking cough, moderate runny nose, red eyes for three days. On examination – enanthem was present on the enanthem hard and soft palate. Grayish white dots were seen opposite the lower molars. lower On fourth day On – temperature: 104ºF. Faint ºF. macules on the upper lateral parts of neck, behind the ears, along the hair line, and on the posterior parts of neck was noticed. parts Major Complications Major Acute Post-infectious Encephalitis – Occurs in 1-4/1000, 2-6 days after rash – Mild to fulminant (death in 24 hours) – 25% morbidity; 15% mortality 25% Subacute Sclerosing Panencephalitis–SSPE Subacute – 2-15 years after infection – Progressive behavioral changes Secondary infections: Pneumonia; flaring of Secondary tuberculosis. tuberculosis. Myocarditis Corneal ulcer Measles: Prognosis Measles: Mortality varies by age / nutritional status – Historically 1-5% Higher with close contact secondary cases from Higher presumed high viral exposure presumed – West Africa/Asia: 25% – Death: pneumonia, malnutrition, diarrhea Risk factors – Immune compromise, Vitamin A deficiency Measles: Treatment Measles: Supportive Care – – – Rest, hydration, nutrition, prn meds Look for and treat bacterial super-infections Rinse eyes daily (saline or sterile water) Vitamin A – – – May decrease mortality by 40% Benefit may be independent of deficiency WHO recs for both hospitalized and less ill Ribavirin – Inhibits viral replication in cell culture – Limited benefit in immune compromised patients – High cost makes = impractical in developing world Measles: Treatment* Measles: Vit-A Vit-A Age 0–5 Months Initial Dose 50,000 IU / day X 2 days 6 – 11 Months >12 >12 Months Months 100,000 IU / day X 2 days 200,000 IU / day X 2 days *WHO Recommendations Final Dose 2 weeks later 50,000 IU 100,000 IU 200,000 IU Some Myths Some Over clothing is essential. Do not use antipyretics. Do not give meat / egg / fruits / oil. Keep in a room with windows closed. Religious Puja. Herbal medicines in eye. My child has three episodes of measles My within one year. within Measles: Prevention Measles: Maternal antibodies – Protect for 3-12 months; usually 6 months – Presence of Ab’s makes vaccine less effective Passive Immunization – Gamma globulin (0.25mg/kg) – For: high risk pts and exposure within 6 days Pregnant, immune suppressed, children too young Pregnant, for vaccine, active TB, leukemia, known HIV for – Impractical for developing world Measles: Prevention Measles: Vaccine Immunization – Live attenuated vaccine – Efficacy (seroconversion) Lifelong immunity 9 months: 80-85% Second dose with MMR at 16 months: >90% – Contraindications (live vaccine) Immune suppressed, leukemia, lymphoma, Immune pregnancy, anaphylaxis to neomycin or gelatin pregnancy, Most recommend vaccinating HIV patients Measles: Prevention Measles: Vitamin A – National Vit. A programme – Targets children >= 6 Targets months old months – Decrease mortality by Decrease improving nutrition improving – Benefit likely involves Benefit many infections, but measles is at the top measles Neonatal Tetanus Neonatal First described by Hippocrates Etiology discovered by Carle and Rattone Etiology in 1984 in Passive immunity used for treatment and Passive prophylaxis during World War I prophylaxis Tetanus toxoid first widely used during Tetanus World War II World Tetanus Pathogenesis Tetanus Anaerobic condition helps to germinate Anaerobic spores and production of toxins. spores Toxins binds to the central nervous system Interferes with the neurotransmitter Interferes release to block inhibitory impulses. release Leads to unopposed muscle contraction Leads and spasm. and Clinical Features Clinical Incubation period: 8 days (3-21 days). Incubation Three clinical forms: –Local (not common) –Cephalilc (rare) –Generalised most common Descending symptoms of trismus, difficulty Descending swallowing, muscle rigidity and spasm. swallowing, Spasm continues ( consciousness Spasm retained) retained) Neonatal tetanus A conscious spasm Tetanus: complications Tetanus: Laryngospasm Hypoglycemia Nosocomial infections Myoglobinuria Aspiration Aspiration Iatrogenic apnoea Iatrogenic Death Management: Principles Management: Eradication of C. tetani. – Penicillin G 100,000 U / kg / 24 hrs. Neutralizing the toxin – Human tetanus immunoglobulin: 500 IU IM – TAT: 10,000 – 100,000 U (I/2 IM and ½ IV) Prevent spasm: – Diazepam: 0.1 – 0.2 mg every 3 – 6 hourly Diazepam: intravenously. intravenously. – Dantrolene; chlorpromazine; baclofen – Vecuronium and pancuronium with Vecuronium Mechanical ventilation (best survival rate) Mechanical Management: contd. Management: IV line. Nasogastric tube feeding. Minimal handling. A separate room. separate Prevention Prevention An entirely preventable disease – Mortality <10% (intensive care treatment) Mortality > 70% without intensive care treatment. 70% Antenatal Tetanus Toxoid www.prsharma.com.np ...
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