兒科學(xué)教學(xué)課件：13-measles

1、MEASLES Acute respiratory infectious disease caused by measles virus Clinical feature: Fever, Cough, Coryza, Conjunctivitis, Exanthem Specific signs: Kopliks Spots hyperpigmentationIntroductionMeasles historySince the beginning of September, 2009, Johannesburg, a city in Gauteng, South Africa report

2、ed about 48 cases of measles. On February 19, 2009, 505 measles cases were reported in twelve provinces in the North of Vietnam, with Hanoi accounting for 160 cases. On The 1st of April 2009, an outbreak has happened in two schools in North Wales. In 2007, a large measles outbreak in Japan caused a

3、number of universities and other institutions to close in an attempt to contain the diseaseApproximately 1000 cases of the disease were reported in Israel between August 2007 and May 2008 (in sharp contrast to just some dozen cases the year before) . As of 2008 the disease is endemic in the United K

4、ingdom with 1,217 cases diagnosed in 2008 and epidemics have been reported in Austria, Italy and Switzerland. In March 2010, Philippines declared an epidemic about the continuously rising cases of measles. Recent outbreaks(WHO) In 2011, large measles outbreaks were reported in all these countries an

5、d several others in:DRC (134 042 cases)Ethiopia (3255 cases)France (14 949 cases)India (29 339 cases)Italy (5189 cases)Nigeria (18 843 cases)Pakistan (4386 cases)Spain (3802 cases)Recent outbreaks(WHO) 2011：9,943 cases 2012: 6,182 cases2013: 27,646 cases2014: 52,628 cases2015: 42,361 cases2016: 24,8

6、20 casesMeasles cases of in-patients in CHCMU (1964-2013)Measles Vaccine Inoculation in whole China (1966)PathogenPathogenmeasles virusPathogen Classification: ssRNA virus Genus: morbillivirus Family: paramyxoviridae Serotype: Only one Location: Patients respiratory secretions Blood, Urine of patien

7、tsCharacterization: Sensitive to heat , ultraviolet light and disinfectant Low temperature resistancePathogenEpidemiologyInfectious sourcesRoutes of transmissionPopulation susceptibilityEpidemic featuresEpidemiologyEpidemiology infective stage:The infective stage is from the late of incubation stage

8、 to the 5th day after rash eruption. If complication occurs, the infective stage prolongs to the 10th day after rash eruption. Infectious sources- PatientsEpidemiology Isolation periodPatients without complication : 5 days after rash eruption. Patients with complication : 10 days after rash eruption

9、. The period of maximum contagiousness is the prodromal stage.Infectious sources- PatientsRoutes of transmissionEpidemiologyDroplet spray2022/8/31EpidemiologyOther Routes of transmissionPopulation susceptibilityEpidemiology It is susceptible to all the people without infection or inoculation. The ag

10、e of peak incidence is from 6 months to 5 years old. Prior to the use of vaccineAfter the use of vaccineMorbidity (1/100000)Mild epidemics: 400Major epidemics: 500-10009.5 in 1990Peak seasonIn winter and springIn any time of a yearEpidemic cycleMajor epidemics appear by 2-4 yr intervalsEpidemic cycl

11、e disappeared, Sporadic cases increasedAge6m-5y (98%10y)Below 6m and teenageClinical manifestationsTypical casessevere manifestationsmore complicationshigh mortality Atypical casesmild manifestationsless complicationsrarely deathEpidemiologyEpidemiological FeaturesPrior to the use of vaccineAfter th

12、e use of vaccineMorbidity (1/100000)Major epidemics: 500-1000Mild epidemics: 4009.5 in 1990Peak seasonIn winter and springIn any time of a yearEpidemic cycleMajor epidemics appear by 2-4 yr intervalsEpidemic cycle disappeared, Sporadic cases increasedAge6m-5y (98%10y)Below 6m and teenageClinical man

13、ifestationsTypical casessevere manifestationsmore complicationshigh mortality Atypical casesmild manifestationsless complicationsrarely deathEpidemiologyEpidemiological FeaturesPrior to the use of vaccineAfter the use of vaccineMorbidity (1/100000)Major epidemics: 500-1000Mild epidemics: 4009.5 in 1

14、990Peak seasonIn winter and springIn any time of a yearEpidemic cycleMajor epidemics appear by 2-4 yr intervalsEpidemic cycle disappeared, Sporadic cases increasedAge6m-5y (98%10y)Below 6m and teenageClinical manifestationsTypical casessevere manifestationsmore complicationshigh mortality Atypical c

15、asesmild manifestationsless complicationsrarely deathEpidemiologyEpidemiological FeaturesPrior to the use of vaccineAfter the use of vaccineMorbidity (1/100000)Major epidemics: 500-1000Mild epidemics: 4009.5 in 1990Peak seasonIn winter and springIn any time of a yearEpidemic cycleMajor epidemics app

16、ear by 2-4 yr intervalsEpidemic cycle disappeared, Sporadic cases increasedAge6m-5y (98%10y)Below 6m and teenageClinical manifestationsTypical casessevere manifestationsmore complicationshigh mortality Atypical casesmild manifestationsless complicationsrarely deathEpidemiologyEpidemiologyEpidemiolog

17、ical FeaturesVaccinationNatural InfectionLife-attenuated strainWild strainBoth antigenicity and pathogenicity are declinedBoth antigenicity and pathogenicity are strongThe antibody level is lowerThe antibody level is higherVaccine related epidemicEpidemiologyEpidemiologyVaccinationNatural InfectionP

18、rotecting levelTimeAntibody levelInfectionvaccination Prior to the use of vaccineAfter the use of vaccineMorbidity (1/100000)Major epidemics: 500-1000Mild epidemics: 4009.5 in 1990Peak seasonIn winter and springIn any time of a yearEpidemic cycleMajor epidemics appear by 2-4 yr intervalsEpidemic cyc

19、le disappeared, Sporadic cases increasedAge6m-5y (98%10y)Below 6m and teenageClinical manifestationsTypical casessevere manifestationsmore complicationshigh mortality Atypical cases increasedmild manifestationsless complicationsrarely deathEpidemiologyEpidemiological FeaturesPathogenesisIncubation p

20、eriodApparent manifestationsPathogenesisRespiratory epitheliumregional lymph nodesPrimary viremiamononuclear phagocytic system Respiratory tract, conjunctiva, skin, etcVirus eliminationsecondary viremiaPathology-Multinucleated giant cell(MGC)Pathology= 100mseveral nucleus inside the cell formed by c

21、onfluence of several virus infected reticulo- endothelial cellsIn smears of the nasal or cheek mucosa in the prodromal stagePathology-Formative process of MGCPathology-Formative process of MGCPathology-Formative process of MGCPathology-Formative process of MGCPathology-Multinucleated giant cell(MGC)

22、Pathology= 100mseveral nucleus inside the cell formed by confluence of several virus infected reticulo- endothelial cellsIn smears of the nasal or cheek mucosa in the prodromal stagePathologyPathology-Cytopathic changeMGC in lung of a measles pneumonia Pathology-OthersPathologyRespiratory tract_gene

23、ral inflammatory reaction Skin Red maculopapular_capillary inflammation at the dermisHyperpigmentation_hemoglobin realised from red cells leak to the outside of the blood vesselDesquamation_cells cornificationPathologyClinical manifestationsIncubation period Prodromal periodExanthemperiodConvalescen

24、t period10-14 days3-4 days3-5 days3-5 daysClinical ManifestationsExposure Incubation stage: 10-14 days Incubation stage (from exposure to the symptoms appearing) lasts 1014 days averagely, but it can as short as 6 days or as long as 21 days sometimes.Clinical Manifestations1.Infected person have con

25、tagiousness in the later period of incubation stage.Incubation period Prodromal periodExanthemperiodConvalescent period10-14 days3-4 days3-5 days3-5 daysClinical ManifestationsExposureClinical manifestationsProdromal stage: 3-4days2. Fever: The magnitude and pattern of fever are variable in patients

26、, from a low-grade to moderate fever or a sudden high fever may occur. Cough Coryza They are not specific symptoms for measles, which are identical to a common cold but catarrhal symptoms maybe more severe. Conjunctivitis May suggest measles before Kopliks spots. Kopliks Spots: Pathognomonic sign Ot

27、her symptoms: anorexia, malaise ,diarrhea,and generalized lymphadenopathy.Clinical manifestationsProdromal stage: 3-4days2. Fever: The magnitude and pattern of fever are variable in patients, from a low-grade to moderate fever or a sudden high fever may occur. Cough Coryza They are not specific symp

28、toms for measles, which are identical to a common cold but catarrhal symptoms maybe more severe. Conjunctivitis May suggest measles before Kopliks spots. Kopliks Spots: Pathognomonic sign Other symptoms: anorexia, malaise ,diarrhea,and generalized lymphadenopathy.Clinical manifestationsProdromal sta

29、ge: 3-4days2. Fever: The magnitude and pattern of fever are variable in patients, from a low-grade to moderate fever or a sudden high fever may occur. Cough Coryza They are not specific symptoms for measles, which are identical to a common cold but catarrhal symptoms maybe more severe. Conjunctiviti

30、s May suggest measles before Kopliks spots. Other symptoms: anorexia, malaise ,diarrhea,and generalized lymphadenopathy. Kopliks Spots: Pathognomonic sign Clinical manifestationsKopliks SpotsA kind of rash present on mucous membranesGrayish spots as small as grain of sand on bright red background of

31、 mucosaMucous membrane opposite the 2nd lower molar, but may spread over the rest of the buccal mucosa.Clinical manifestationsKopliks spots on cheek mucosa Kopliks spots on palate Appear and disappear rapidly (1 - 2 days before the rash to 1- 2 days after the rash) Clinical manifestationsProdromal s

32、tage: 3-4days2. Fever: The magnitude and pattern of fever are variable in patients, from a low-grade to moderate fever or a sudden high fever may occur. Cough Coryza They are not specific symptoms for measles, which are identical to a common cold but catarrhal symptoms maybe more severe. Conjunctivi

33、tis May suggest measles before Kopliks spots. Kopliks Spots: Pathognomonic sign Other symptoms: anorexia, malaise ,diarrhea, and generalized lymphadenopathy.Clinical manifestationstypical facial appearance of measles in prodromal stage Clinical manifestationsExanthem stage: 3-5days Maculopapular ras

34、h: main manifestationAppearance Sequence Fever: temperature rises abruptly Catarrh: Other manifestations:3.Clinical manifestationsMaculopapular rashRed blotchy Flat or slightly raised rash. Uneven with 0.1-1.0 cm in diameter.Lesions blanch with fingertip pressure. Inching is generally slightClinical

35、 manifestationsStarts as individual The skin among rash looks like normal Blend into each other as more appear Maculopapular rashClinical manifestationsExanthem stage: 3-5days Maculopapular rash: main manifestationAppearance Sequence Fever: temperature rises abruptly Catarrh: Other manifestations:3.

36、Clinical manifestations-appearing sequence of the rashThe rash usually starts on the upper lateral parts of the neck, behind the ears, along the hairlineClinical manifestationsClinical manifestations-appearing sequence of the rashIt become increasingly maculopapular as the rash spreads rapidly over

37、the entire face, neck, upper arms, and upper part of the chest within approximately the 24hr. Clinical manifestations-appearing sequence of the rash Sequence: behind the earalong the hairlinefaceneckchestbackabdomenlimbshand and feet(palm,sole) Clinical manifestations Maculopapular rash: main manife

38、station Fever: temperature rises Cough Coryza Conjunctivitis Other manifestations:Exanthem stage: 3-5days3.Clinical manifestationsFever: temperature rises abruptlyCatarrh: Maculopapular rash: main manifestation Other manifestations: light hepatomegaly and splenomegaly, enlarged lymph nodes gastroint

39、estinal symptoms Exanthem stage: 3-5days3.Clinical manifestationsConvalescent stage: 3-5 days All symptoms relieve gradually. Fever , Cough, Coryza and Conjunctivitis relieve The rash fades in the same order it erupts Branny desquamation brownish discoloration disappear within 2-3 weeks. 4.Clinical

40、manifestationsBranny desquamation Brownish discoloration (hyperpigmentation) Significant for the restrospective diagnosis for measlesConvalescent stage: 3-5 days 4.Clinical manifestations The rash appears after 34 days of onset of fever The rash is maculopapular. It starts on the skin behind the ear

41、s. Within 35 days, it spreads from the head down to the full body gradually. It fades in the same order it appears. With fading, branny desquamation and brownish discoloration occur.-Summary of rash Temp Kopliks spotsRashBranny desquamation & hyperpigmentation Summary of typical clinical features414

42、039383736Clinical periodsProdromal stageExanthem stageConvalescent stageDays 1-141234567891011121314Coryza and conjunctivitisCoughComplicationsComplications 1. Pneumonia 2. Laryngitis 3. Encephalitis and Subacute sclerosing pan-encephalitis (SSPE) 4. Exacerbation of tuberculosis 5. Malnutrition and

43、Vitamin A deficiency ComplicationsPneumonia is the most frequent complication of measles and it is the leading cause of death in measles. The younger the children, the more frequent of pneumonia. Two causes may involved: (1) Primary pneumonia Caused by the measles virus directly. (2) Secondary pneum

44、onia Caused by superinfection of bacteria other virus and fangi.- Pneumonia High fever More severe cough with restlessness, breathlessness and cyanosis Physical examination of the chest: bronchial breath sounds and rales in auscultation Chest X-ray examination: Presence of infiltrate and patchy chan

45、ge in lung Complications- PneumoniaComplications The second most frequent complication Causes: measles virus, other viruses or bacteria Laryngitis is more common and more severe in younger children. Swollen larynx can further narrow the small airway and lead to breathing difficulties, even a fatal r

46、espiratory obstruction.- Laryngitis Hoarseness Barkly cough (cough sounds like a bark) Wheezing sound at the each time of breath Unusual restlessness or sleepiness Cyanosis Complications- Laryngitis Complications The incidence of encephalitis is estimated to be 1-2/1000 cases of measles. No correlat

47、ion between the severity of the rash and the onset of encephalitis The cause of measles encephalitis is considered to be the directly invasion of measles virus. - EncephalitisHeadache, nausea, vomiting, meningeal irritation, convulsion, conscious disturbance Clinical feature: 2-5 days after the rash

48、 eruption similar to encephalitis caused by other virusComplications- EncephalitisComplications SSPE is a quite rare complication with a low incidence of 1/1,000,000 It is a chronic encephalitis caused by persistent infection of mutational measles virus in central nervous system Long interval betwee

49、n the onset of measles and SSPEThe high risk of age is 5-15 years old.- Subacute sclerosing panencephalitis (SSPE)Complications - Subacute sclerosing panencephalitis (SSPE) The onset is usually insidious and is marked by subtle changes in behavior and deterioration of schoolwork. Then the neurologic

50、 symptom becomes progressively more severe by the appearance of seizure, dystonia, ataxia, dementia, and coma. Poor prognosis: Few patients live for above 3 years after the diagnosis of SSPE, and those who do survive longer are usually disabled.Complications-Exacerbation of tuberculosis infectionStr

51、ong evidence suggests that the virus invades monocytes and can lead to secondary immunosuppression. Both cellular immunity and humoral immunity are affected. Underlying tuberculosis change to active TB disseminated TB tuberculous meningitis A temporary loss of hypersensitivity reaction to tuberculin

52、 skin testing-Malnutrition and Vitamin A deficiencyComplications Persistence of high fever Malfunction of gastrointestinal tract Old bad tradition Clinical features: night blindness, corneal ulceration, blindness, etc Routine administration of vitamin A with measles Lab studiesLab studies The white

53、blood cell count and differential WBC tends to be low and LC is relatively high e.g. WBC 3.4109/L N 0.24 L 0.76 WBC 15.2109/L N 0.81 L 0.19Lab studies Multinucleated giant cells can be demon strated in smears of the buccal mucosa during the prodromal stage. Testing of specific IgM in serum Measles v

54、irus isolationDiagnosisDiagnosis Epidemiologic data Clinical data Laboratory dataDiagnosis -Epidemiologic dataAgeSeasonHistory of contact with patientHistory of inoculationDiagnosis-Clinical dataProdromal periodConvalescent periodKopliks spotsTypical rash Correlation of rash and fever3CBranny desqua

55、mation Brownish discolorationExanthem periodDiagnosis -Laboratory data Multinucleated giant cells Testing of specific IgM in serum The diagnosis is usually made from the characteristic clinical picture, laboratory confirmation is rarely needed.Differential DiagnosisDifferential diagnosis Rubella Ros

56、eola infantum Enterovirus infection Differential diagnosis Rubella Differential diagnosis -Rubella (German Measles ) Short prodromal stage with only 1-2 daysRash covers the full body more rapid (within 24 hours) The rash is smaller Without occurrence of branny desquamation and brownish discoloration

57、 in the convalescent stageAbsence of Kopliks spotsEnlarged of the occipital lymph node and retroauricular lymph nodes An exanthem disease caused by rubella virus Presence of fever, cough, mild coryza and maculopapular rash.Differential diagnosisDifferential diagnosis -Rubella (German Measles ) Short

58、 prodromal stage with only 1-2 daysRash covers the full body more rapid (within 24 hours) The rash is smaller Without occurrence of branny desquamation and brownish discoloration in the convalescent stageAbsence of Kopliks spotsEnlarged of the occipital lymph nodes and retroauricular lymph nodes An

59、exanthem disease caused by rubella virus Presence of fever, cough, mild coryza and maculopapular rash. -Roseola infantum An exanthem disease caused by human herpesvirus 6, commonly occurs in toddlers. Differential diagnosis Presence of fever, maculopapular rash and slight cough. The rash appears aft

60、er 34days of fever.Differential diagnosisRoseola infantum MeaslesThe rash typically appears when the elevated temperature has abated, and can last for only 1-2days before subsiding. -Roseola infantum An exanthem disease caused by human herpesvirus 6, commonly occurs in toddlers. Rash appears as the