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Unformatted text preview: Measles and Neonatal Tetanus:
Measles and Neonatal Tetanus:
Clinical Signs and Treatment
Clinical Signs and Treatment
Prof. Pushpa Raj Sharma
Institute of Medicine
Kathmandu Measles Case definition
Laboratory confirmation in the absence of
recent immunization (1-14 days) with
measles containing vaccine:
– Detection of measles virus from urine or
throat/nasopharyngeal swabs or
– Significant rise in the measles antibody titre
between acute and convalescent sera or
– Positive serologic test for measles IgM
antibody using a recommended assay.
antibody Measles: Basic Characteristics
Also known as “dadura”/”bhosa kai” / rubeola /
fourth day disease/ first fever
Acute viral illness
Primarily affects children
– RNA, single stranded Vaccine preventable
– Potential to be eliminated Measles: Signs and Symptoms
Incubation period: 10-12 days (8-16 range)
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
Chronic, serious if previously malnourished Measles:
– 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
Behind Ears Erythematous papular
eruption Face Travels inferior over 2-3
days Trunk Coalesces into macular
“splotches” Limbs Often desquamates at end
of Measles: Signs and Symptoms
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
– Complete recovery in 10-14 days Summary: Diagnosis / Clinical
Clinical illness includes all of
the following symptoms:
– Temperature of 38.3°C or
– Cough, coryza or conjunctivitis
– Generalized maculopapular
rash for at least three days
following temperature and
cough, coryza or conjunctivitis.
cough, Koplik’s spots can be classic,
but easily missed
but Dengue Measles
Enteroviruses Rubella Kawasaki Maculopapular Rash
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.
seizure on the third day.
No specific localizing
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
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
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
Rash and fever same time
Rash last 3-5 days Case history:
Five years , child
Five – moderate fever, a hacking cough,
runny nose, red eyes for three
days. On examination – enanthem was present on the
hard and soft palate. Grayish
white dots were seen opposite the
lower On fourth day
On – temperature: 104ºF. Faint
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
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
– 2-15 years after infection
– Progressive behavioral changes Secondary infections: Pneumonia; flaring of
Corneal ulcer Measles: Prognosis
Mortality varies by age / nutritional status
– Historically 1-5%
Higher with close contact secondary cases from
presumed high viral exposure
presumed – West Africa/Asia: 25%
– Death: pneumonia, malnutrition, diarrhea Risk factors
– Immune compromise, Vitamin A deficiency Measles: Treatment
– 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*
Months Initial Dose
50,000 IU / day
X 2 days 6 – 11
Months 100,000 IU / day
X 2 days
200,000 IU / day
X 2 days *WHO Recommendations Final Dose
2 weeks later
200,000 IU Some Myths
Over clothing is essential.
Do not use antipyretics.
Do not give meat / egg / fruits / oil.
Keep in a room with windows closed.
Herbal medicines in eye.
My child has three episodes of measles
within one year.
within Measles: Prevention
– 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
for vaccine, active TB, leukemia, known HIV
for – Impractical for developing world Measles: Prevention
– Live attenuated vaccine
– Efficacy (seroconversion)
9 months: 80-85%
Second dose with MMR at 16 months: >90% – Contraindications (live vaccine)
Immune suppressed, leukemia, lymphoma,
pregnancy, anaphylaxis to neomycin or gelatin
Most recommend vaccinating HIV patients Measles: Prevention
– National Vit. A programme
– Targets children >= 6
– Decrease mortality by
– Benefit likely involves
many infections, but
measles is at the top
measles Neonatal Tetanus
First described by Hippocrates
Etiology discovered by Carle and Rattone
Passive immunity used for treatment and
prophylaxis during World War I
Tetanus toxoid first widely used during
World War II
World Tetanus Pathogenesis
Anaerobic condition helps to germinate
spores and production of toxins.
Toxins binds to the central nervous system
Interferes with the neurotransmitter
release to block inhibitory impulses.
Leads to unopposed muscle contraction
and Clinical Features
Incubation period: 8 days (3-21 days).
Three clinical forms:
–Local (not common)
–Generalised most common Descending symptoms of trismus, difficulty
swallowing, muscle rigidity and spasm.
Spasm continues ( consciousness
retained) Neonatal tetanus A conscious spasm Tetanus: complications
Death Management: Principles
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
– Dantrolene; chlorpromazine; baclofen
– Vecuronium and pancuronium with
Mechanical ventilation (best survival rate)
Mechanical Management: contd.
Nasogastric tube feeding.
A separate room.
An entirely preventable disease
– Mortality <10% (intensive care treatment)
> 70% without intensive care treatment.
70% Antenatal Tetanus Toxoid www.prsharma.com.np ...
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- Fall '11