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SECTION I

Case Report

IDENTITY

Patient  Name : L.A

Birth Date : May 4th, 200

A!e : "0 years # mo$ths

%e$&er : Ma'e

A&&ress : (p Ta$!si RT#)R*+ Ciara$!, East -aarta

 Natio$a'ity : I$&o$esia

Re'i!io$ : Mos'em

MR No. : +0//

Date o1 a&missio$ : A!st 2th  20"

Date o1 eami$atio$ : A!st 2th 20"

Father Mother

Name Mr. S Mrs. M

Age 40 years o'& # years o'&

Job Emp'oyee 3osei1e

Nationality I$&o$esia$ I$&o$esia$

Religion Mos'em Mos'em

Education 3i!h S5hoo' 3i!h S5hoo'

Earning/month Rp..000.000,

Address (p Ta$!si RT#)R*+ Ciara$!, East -aarta

ANAMNESIS

The a$am$esis as tae$ o$ A!st 2th 20", si$! a''oa$am$esis metho&.

The a$am$esis tae$ at room $o.+ A$!!re II *ar&, RS 6OLRI R Sai& Sa$to

hie! com#lain $ 7e8er si$5e 1or &ays prior to a&missio$ at hospita'.

Additional com#lains :Rash, 5o!h, 1', hea&a5he, $asea, 8omiti$!, &iarrhea,

a9&omi$a' pai$

3istory O1 6rese$t I'$ess

A "0 years # mo$ths o'& 9oy ith 9o&y ei!ht 2+ !, 5ame to Ra&e$ Sai&

Sa$to 6o'i5e Ce$ter 3ospita' ER at 0/.#0 am, ith a 5hie1 5omp'ai$ o1 1e8er. The

1e8er 'asts 1rom 4 &ays 9e1ore a&missio$ to the hospita'. The mother says that the

1e8er are s&&e$ 9e5ame hi!h a$& o$t !oes &o$. The 1e8er 5ame p hi!h at $oo$.

The mother !a8e pa$a&o' to &e5rease the temperatre. This 5omp'ai$s a'so 1o''oe&

 9y rash a'' o8er his 9o&y, 5o!h, 1', hea&a5he, $asea, 8omiti$!, &iarrhea, a9&omi$a'

 pai$ si$5e 4 &ays a$& sa''oi$! pai$ si$5e " &ay 9e1ore a&missio$.

3istory O1 6ast I''$ess

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6hary$!itis)To$si'itis ;

Bro$5hitis

6$emo$ia

Mor9i''i

6ertssis

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De(elo#ment %istory

7irst &e$titio$: + mo$ths o'&

6sy5homotor &e8e'opme$t

Smi'e : " mo$th o'&

S'a$t : 2 mo$ths o'&

Spee5h I$itatio$ : 2 mo$ths o'&

6ro$e 6ositio$ : 4 mo$ths o'&

Sitti$! : + mo$ths o'&

Cra'i$! : = mo$ths o'&

Sta$&i$! : "0 mo$ths o'&

*a'i$! : "2 mo$ths o'&

Co$5'sio$: !roth a$& &e8e'opme$ta' is sti'' i$ the $orma' 'imits a$& as

appropriate a55or&i$! to the patie$ts a!e

Post Natal %istory

 A1ter 9irth, the 9a9y 5he5e& at 'o5a' &o5tor a$& the i$1a$t state is hea'thy.

3istory o1 Eati$!

Breast Mi' : + mo$ths.

7orm'a mi' : S%M si$5e / mo$ths o'&

Ba9y 9is5its : Mi'$a, Re!a'

7rit a$& 8e!eta9'es : Ba$a$a, papaya

So'i& 1oo&s a$& si&e &ishes : Ba9y porri&!e

Imm$i?atio$ 3istory

Imm$i?atio$ 7re@e$5y Time

BC% " time " mo$th o'&

3epatitis B # times 0, ", + mo$ths o'&

D6T # times 2, 4, + mo$ths o'&

6o'io 4 times 0, 2, 4, + mo$ths o'&

3i9 4 times 2, 4, +, mo$ths o'&

Meas'es " time mo$ths o'&

7ami'y 3istory

• 6atie$ts 1ather &i&$t ha8e hyperte$sio$ $or &ia9etes me''its

• 6atie$ts mother &i&$t ha8e hyperte$sio$ $or &ia9etes me''its

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The patie$t has " sister, a$& he is the 1irst 5hi'& o1 2 si9'i$!s.

Bor$ &ie& :

Chi'& &ies :

Mis5arria!e :

3istory o1 Disease i$ Other 7ami'y Mem9ers ) Aro$& the 3ose

3er $ei!h9ors so$ ha& meas'es a ee a!o.

P%YSIA) E*AMINATI+N ,August -.th  -0.1

2eneral Status

- %e$era' 5o$&itio$ : Mi'&'y i''

- Co$s5ios$ess : Compos Me$tis

- 6'se : "00 )mi$, re!'ar, 1'', stro$!.

- Breathi$! rate : 20 )mi$

- Temperatre : #=.#o C per ai''a

Anthro#ometry Status

-*ei!ht : 2+ i'o!ram

-3ei!ht : "#" 5m

 Ntritio$a' Stats 9ase& NC3S Natio$a' Ce$ter 1or 3ea'th Statisti5s year 2000:

*7A Weight for Age: 2+)#" "00 =# !oo& $tritio$

37A 3ei!ht 1or A!e: "#")"#/ "00 !oo& $tritio$

*73 *ei!ht 1or 3ei!ht: 2+)2+ "00 "00 !oo& $tritio$

Conclusion: The patient has good nutritional status.

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%ead to Toe E3amination

 

%ead

 Normo5epha'y, hair 9'a5, $orma' &istri9to$, $ot easi'y remo8e& si!$ o1 

trama , 'ar!e 1o$ta$e''e 5'ose&. Rash ,41

 

Eyes

I5teri5 s5'era ), pa'e 5o$F$5ti8a ), hy#eraemia con5uncti(a 4/4,

'a5rimatio$ ), s$e$ eyes ), ppi's #mm)#mm isoor, Dire5t a$& i$&ire5t

'i!ht respo$se ;;);;

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Ears

 Norma' shape, $o o$&, $o 9'ee&i$! ,se5retio$ or serme$. Rash ,41

 

Nose

 Norma' shape, mi&'i$e septm, se5retio$ ). Rash ,41

 

Mouth

− Lips: &ry

− Teeth: $o 5aries

− M5os: moist

− To$!e: Not &irty

− To$si's: T")T", No hyperemia

− 6hary$: hyperemia

 

Nec6 

Lymph $o&e e$'ar!eme$t ;, s5ro1'o&erma , Rash ,41

 

Thora3 :

i7 I$spe5tio$ : symmetri5 he$ 9reathi$!  8 $o retra5tio$,  i5ts 5or&is is $ot

8isi9'e. Rash ,41

ii7 6a'patio$ : mass , ta5ti'e 1remits ;);

iii7 6er5ssio$ : so$or o$ 9oth '$!s

i(7 As5'tatio$ :". Cor : re!'ar S"S2, mrmr , !a''op

2. 6'mo : 8esi5'ar ;);, *hee?i$! ) , Rho$5hy )

 

Abdomen :

i7 I$spe5tio$ : Co$8e, epi!astri5 retra5tio$ , there is $o a i&e$i$! o1 the

8ei$s, $o spi&er $e8i. Rash ,41

ii7 As5'tatio$ : 9oe' so$& $orma' , 9rit

iii7 6a'patio$ : spp'e, 'i8er a$& sp'ee$ $ot pa'pa9'e, 1'i& a8e ,

a9&omi$a' mass

i(7 6er5ssio$ : The e$tire 1ie'& o1 tympa$i5 a9&ome$, shi1ti$! &''$ess

 

9ertebra : There &oes $ot appear s5o'iosis, yphosis, a$& 'or&osis, &o $ot

'oo a$y mass a'o$! the 'i$e o1 the 8erte9ra'

E6stremities : arm, 5api''ary re1i'' time G 2 se5o$&, e&ema rash ,41

 

S6in : %oo& tr!or.

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Neurological E3amination

Meningeal Sign

Motoric E3amination

Po:er

  3a$&  7eet

) )

Tonus

  3a$&

  7eet

 Normoto$s ) Normoto$s

 Normoto$s ) Normoto$s

Tro#hy

  3a$&

  7eet

 Normotrophy ) Normotrophy

 Normotrophy ) Normotrophy

Physiologic Re!le3

  Hpper etrimities

  Bi5eps

  Tri5eps

  Loer etrimities

  6ate''a

A5hi''es

 

; ) ;

; ) ;

; ) ;

; ) ;

Pathologic Re!le3

  Hpper etrimities

  3o11ma$

  Trommer 

  Loer etrimities

  Ba9i$sy

  Cha&&o5 

  Oppe$heim

  %or&o$

  S5hae11er 

)

)

)

)

)

)

)

lonus

  6ate''a

  A5hi''es

)

)

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Autonom E3amination

 

De1e5atio$

  Hri$atio$

  Seati$!

 Norma' " times &ai'y, $orma' 5o$siste$5y

 Norma' 4 times &ai'y

 Norma'

)aboratory In(estigation

%ematology August -.th -0.

3emato'o!y Res'ts Norma'

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O %e$era' 5o$&itio$: Compos Me$tis

3eart rate "00 )mi$

Respiratory rate 2+ )mi$

Temperatre #/.C

Car&io : S")S2, re!'er, $o mrmr, $o !a''op

6'mo$ary : 8esi5'er ;);, rho$5hi ), hee?i$! )A9&ome$ : &iste$tio$ , 9oe' so$& ; $orma'

Rash ,41

 

A Mor9i''i

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7e8er

Rash ;

Cory?a ;

O %e$era' 5o$&itio$: Compos Me$tis

3eart rate ""0 )mi$

Respiratory rate 24 )mi$Temperatre #+C

Car&io : S")S2, re!'er, $o mrmr, $o !a''op

6'mo$ary : 8esi5'er ;);, rho$5hi ), hee?i$! )

A9&ome$ : &iste$tio$ , 9oe' so$& ; $orma'

Rash ,41

A Mor9i''i

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SECTION II

LITERATHRE O7 RE

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o1 rash. Approimate'y 0 o1 epose& ss5epti9'e i$&i8i&a's eperie$5e meas'es.

7a5eto1a5e 5o$ta5t is $ot $e5essary, 9e5ase 8ia9'e 8irs may 9e sspe$&e& i$ air 1or 

as 'o$! as " hor a1ter the patie$t ith the sor5e 5ase 'ea8es a room. Se5o$&ary 5ases

&e to sprea& o1 aeroso'i?e& 8irs ha8e 9ee$ reporte& i$ physi5ia$s o11i5es a$& i$

hospita's.

Meas'es i$1e5tio$ 5ases $e5rosis o1 the respiratory tra5t epithe'im a$& a$

a55ompa$yi$! 'ympho5yti5 i$1i'trate. Meas'es pro&5es a sma'' 8esse' 8as5'itis o$

the si$ a$& o$ the ora' m5os mem9ra$es. 3isto'o!y o1 the rash a$& ea$them

re8ea's i$tra5e'''ar e&ema a$& &yseratosis asso5iate& ith 1ormatio$ o1 epi&erma'

sy$5ytia' !ia$t 5e''s ith p to 2+ $5'ei.

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C'i$i5a' Ma$i1estatio$s

Meas'es is a serios i$1e5tio$ 5hara5teri?e& 9y hi!h 1e8er, e$a$them 5o!h, 5ory?a,

5o$F$5ti8itis, a$& a promi$e$t ea$thema. A1ter a$ i$59atio$ perio& o1 ="2 &ays,

the pro&roma' phase 9e!i$s ith a mi'& 1e8er 1o''oe& 9y the o$set o1 5o$F$5ti8itis

ith photopho9ia, 5ory?a, a promi$e$t 5o!h, a$& i$5reasi$! 1e8er. (op'i spots

represe$t the e$a$them a$& are the patho!$omo$i5 si!$ o1 meas'es, appeari$! " to 4

&ays prior to the o$set o1 the rash. They 1irst appear as &is5rete re& 'esio$s ith 9'ish

hite spots i$ the 5e$ter o$ the i$$er aspe5ts o1 the 5hees at the 'e8e' o1 the

 premo'ars. They may sprea& to i$8o'8e the 'ips, har& pa'ate, a$& !i$!i8a. They a'so

may o55r i$ 5o$F$5ti8a' 1o'&s a$& i$ the 8a!i$a' m5osa. (op'i spots ha8e 9ee$

reporte& i$ 0/0 o1 meas'es 5ases 9t pro9a9'y o55r i$ the !reat maFority.

Symptoms i$5rease i$ i$te$sity 1or 24 &ays $ti' the "st &ay o1 the rash Erptio$

 phase. The rash 9e!i$s o$ the 1orehea& aro$& the hair'i$e, 9ehi$& the ears, a$& o$

the pper $e5 as a re& ma5'opap'ar erptio$. It the$ sprea&s &o$ar& to the torso

a$& etremities, rea5hi$! the pa'ms a$& so'es i$ p to 0 o1 5ases. The ea$them

1re@e$t'y 9e5omes 5o$1'e$t o$ the 1a5e a$& pper tr$.

*ith the o$set o1 the rash, symptoms 9e!i$ to s9si&e. The rash 1a&es o8er a9ot /

&ays i$ the same pro!ressio$ as it e8o'8e&, o1te$ 'ea8i$! a 1i$e &es@amatio$ o1 si$

i$ its ae Co$8a'es5e$ts) Re5o8ery 6hase . O1 the maFor symptoms o1 meas'es, the

5o!h 'asts the 'o$!est, o1te$ p to "0 &ays. I$ more se8ere 5ases, !e$era'i?e&

'ympha&e$opathy may 9e prese$t, ith 5er8i5a' a$& o55ipita' 'ymph $o&es espe5ia''y

 promi$e$t

I$ i$&i8i&a's ith passi8e'y a5@ire& a$ti9o&y, s5h as i$1a$ts a$& re5ipie$ts o1 

 9'oo& pro&5ts, a s95'i$i5a' 1orm o1 meas'es may o55r. The rash may 9e i$&isti$5t,

 9rie1, or, rare'y, e$tire'y a9se$t. Lieise, some i$&i8i&a's ho ha8e re5ei8e&

8a55i$e, he$ epose& to meas'es, may ha8e a rash 9t 1e other symptoms. 6erso$s

ith i$appare$t or s95'i$i5a' meas'es &o $ot she& meas'es 8irs a$& &o $ot tra$smit

i$1e5tio$ to hoseho'& 5o$ta5ts.

Chi'&re$ ho ha& re5ei8e& the ori!i$a' 1orma'i$i$a5ti8ate& meas'es 8a55i$e at times

&emo$strate& a more se8ere 1orm o1 &isease 5a''e& atypi5a' meas'es. S5h patie$tsha& o$set o1 hi!h 1e8er a$& hea&a5he 1o''oe& 9y the appeara$5e o1 a ma5'opap'ar 

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rash o$ the etremities that 9e5ome pete5hia' a$& prpri5 a$& pro!resse& i$ a

5e$tripeta' &ire5tio$. 6$emo$ia a$& p'era' e11sio$s 1re@e$t'y 5omp'i5ate& the

i''$ess. It is tho!ht that atypi5a' meas'es as 5ase& 9y &e8e'opme$t o1 5ir5'ati$!

imm$e 5omp'ees that 1orme& as a res't o1 a$ a9$orma' imm$e respo$se to the

8a55i$e.

La9oratory Data

The &ia!$osis o1 meas'es is a'most a'ays 9ase& o$ 5'i$i5a' a$& epi&emio'o!i5

1i$&i$!s. La9oratory 1i$&i$!s i$ the a5te phase i$5'&e re&5tio$ i$ the tota' hite

 9'oo& 5e'' 5o$t, ith 'ympho5ytes &e5rease& more tha$ $etrophi's. A9so'te

$etrope$ia has 9ee$ $o$ to o55r, hoe8er. I$ meas'es $ot 5omp'i5ate& 9y

 9a5teria' i$1e5tio$, the erythro5yte se&ime$tatio$ rate a$& Crea5ti8e protei$ 'e8e' are

$orma'.

A$ti9o&y Assays

The meas'es 8irs sa$&i5h5aptre I!M a$ti9o&y assay, is the

@i5est metho& o1 5o$1irmi$! a5te meas'es. Be5ase I!M may $ot 9e

&ete5ta9'e &ri$! the 1irst 2 &ays o1 rash, o9tai$ 9'oo& 1or meas'esspe5i1i5

I!M o$ the thir& &ay o1 the rash or o$ a$y s9se@e$t &ay p to " mo$th a1ter 

o$set to a8oi& a 1a'se$e!ati8e I!M res't.

Amo$! perso$s ith 5o$1irme& meas'es i$1e5tio$, the seropositi8ity

rate 1or 1irst samp'es is a9ot // he$ 5o''e5te& ithi$ /2 horsP the rate

rises to "00 he$ 5o''e5te& 4"" &ays a1ter rash o$set. A'tho!h the meas'es

serm I!M 'e8e' remai$s positi8e #0+0 &ays a1ter the i''$ess i$ most

i$&i8i&a's, the I!M titer may 9e5ome $&ete5ta9'e i$ some s9Fe5ts at 4

ees a1ter rash o$set. 7a'sepositi8e res'ts 5a$ o55r i$ patie$ts ith

rhemato'o!i5 &iseases, par8o8irs B" i$1e5tio$, or i$1e5tios

mo$o$5'eosis.

Imm$o!'o9'i$ %

La9oratories 5a$ 5o$1irm meas'es 9y &emo$strati$! more tha$ a 41o'&

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rise i$ I!% a$ti9o&ies 9etee$ a5te a$& 5o$8a'es5e$t sera, a'tho!h re'yi$!

so'e'y o$ risi$! I!% titers 1or the &ia!$osis &e'ays treatme$t 5o$si&era9'y. The

ear'ier the a5te serm is &ra$, the more re'ia9'e the res'ts. I!% a$ti9o&ies

may 9e &ete5ta9'e 4 &ays a1ter the o$set o1 the rash, a'tho!h most 5ases ha8e

&ete5ta9'e I!% a$ti9o&ies 9y a9ot a ee a1ter rash o$set.

A55or&i$!'y, it is re5omme$&e& that spe5ime$s 9e &ra$ o$ the

se8e$th &ay a1ter rash o$set. B'oo& &ra$ 1or 5o$8a'es5e$t serm sho'& 9e

&ra$ "0"4 &ays a1ter that &ra$ 1or a5te serm, a$& the a5te a$&

5o$8a'es5e$t sera sho'& 9e teste& sim'ta$eos'y as paire& sera.

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Dia!$osis

I$ the a9se$5e o1 a re5o!$i?e& meas'es ot9rea, 5o$1irmatio$ o1 the 5'i$i5a'

&ia!$osis is o1te$ re5omme$&e&. Sero'o!i5 5o$1irmatio$ is most 5o$8e$ie$t'y ma&e

 9y i&e$ti1i5atio$ o1 imm$o!'o9'i$ M I!M a$ti9o&y i$ serm. Sero'o!i5

5o$1irmatio$ may a'so 9e ma&e 9y &emo$stratio$ o1 a 1or1o'& rise i$ I!% a$ti9o&ies

i$ a5te a$& 5o$8a'es5e$t spe5ime$s 5o''e5te& 24 ees 'ater.

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(op'i spots a$& a se8ere pro&roma' 5o!h, a$& typi5a''y 'ea&s to e'e8atio$s o1 

$etrophi's a$& a5tephase rea5ta$ts. I$ a&&itio$, the 5hara5teristi5 throm9o5ytosis

o1 (aasai sy$&rome is a9se$t i$ meas'es. Dr! erptio$s may o55asio$a''y 9e

mistae$ 1or meas'es.

The &ia!$osis o1 meas'es is sa''y &etermi$e& 1rom the 5'assi5 5'i$i5a'

 pi5tre, i$5'&i$! the 5'assi5 tria& o1 5o!h, 5ory?a, a$& 5o$F$5ti8itisP the

 patho!$omo$i5 (op'i spotsP a$& the 5hara5teristi5 5epha'o5a&a' pro!ressio$ o1 the

mor9i''i1orm ea$them.

It is orthhi'e to 9e mi$&1' o1 the sy$&rome $o$ as atypi5a' meas'es,

hi5h has 9ee$ &es5ri9e& i$ i$&i8i&a's ho ere i$1e5te& ith i'& meas'es 8irs

se8era' years a1ter imm$i?atio$ ith a i''e& meas'es 8a55i$e a 8a55i$e se& i$ the

H$ite& States 1rom "+#"+/. This sy$&rome te$&s to 9e more pro'o$!e& a$&

se8ere tha$ re!'ar meas'es a$& is mare& 9y a pro'o$!e& hi!h 1e8er, p$emo$itis,

a$& a rash that 9e!i$s periphera''y a$& may 9e rti5aria', ma5'opap'ar,

hemorrha!i5, a$&)or 8esi5'ar.

The assme& patho!e$esis o1 atypi5a' meas'es is hyperse$siti8ity to meas'es

8irs i$ a partia''y imm$e host. La9oratory tests re8ea' a 8ery 'o meas'es a$ti9o&y

titer ear'y i$ the 5orse o1 the &isease, 1o''oe& soo$ therea1ter 9y the appeara$5e o1 

a$ etreme'y hi!h meas'es imm$o!'o9'i$ % I!% a$ti9o&y titer e!, ":",000,000

i$ the serm.

Other &ia!$oses to 9e 5o$si&ere& i$5'&e the 1o''oi$!:

(aasai &isease

De$!e

Serm si5$ess

Syphi'is

Systemi5 'ps erythematoss

Toi5 sho5 sy$&rome

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Treatme$t

Ma$a!eme$t o1 meas'es is spporti8e. A$ti8ira' therapy is $ot e11e5ti8e i$ the

treatme$t o1 meas'es i$ otherise $orma' patie$ts. Mai$te$a$5e o1 hy&ratio$,

oy!e$atio$, a$& 5om1ort are !oa's o1 therapy. A$tipyreti5s 1or 5om1ort a$& 1e8er 

5o$tro' are se1'. 7or patie$ts ith respiratory tra5t i$8o'8eme$t, airay hmi&i

1i5atio$ a$& spp'eme$ta' oy!e$ may 9e o1 9e$e1it. Respiratory 1ai're &e to 5rop

or p$emo$ia may re@ire 8e$ti'atory spport. Ora' rehy&ratio$ is e11e5ti8e i$ most

5ases, 9t se8ere &ehy&ratio$ may re@ire i$tra8e$os therapy. 6rophy'a5ti5 a$ti

mi5ro9ia' therapy to pre8e$t 9a5teria' i$1e5tio$ is $ot i$&i5ate&.

Meas'es i$1e5tio$ i$ imm$o5ompromise& patie$ts is hi!h'y 'etha'. Ri9a8iri$

is a5ti8e i$ 8itro a!ai$st meas'es 8irs. A$e5&ota' reports o1 ri9a8iri$ therapy ith or 

ithot i$tra8e$os !amma !'o9'i$ s!!est some 9e$e1it i$ i$&i8i&a' patie$ts.

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Comp'i5atio$s

Comp'i5atio$s o1 meas'es are 'ar!e'y attri9ta9'e to the patho!e$i5 e11e5ts o1 

the 8irs o$ the respiratory tra5t a$& imm$e system Se8era' 1a5tors mae

5omp'i5atio$s more 'ie'y. Mor9i&ity a$& morta'ity 1rom meas'es are !reatest i$

 patie$ts years o1 a!e espe5ia''y " years o1 a!e a$& 20 years o1 a!e. I$

&e8e'opi$! 5o$tries, hi!her 5ase 1ata'ity rates ha8e 9ee$ asso5iate& ith 5ro&i$!,

hi5h are possi9'y attri9ta9'e to 'ar!er i$o5'm &oses a1ter hoseho'& eposre.

Se8ere ma'$tritio$ i$ 5hi'&re$ res'ts i$ s9optima' imm$e respo$se a$& hi!her 

mor9i&ity a$& morta'ity ith meas'es i$1e5tio$. Meas'es i$1e5tio$ 'oers serm

reti$o' 5o$5e$tratio$s, so s95'i$i5a' 5ases o1 hyporeti$o'emia may 9e ma&e

symptomati5 &ri$! meas'es. Meas'es i$1e5tio$ i$ imm$o5ompromise& perso$s is

asso5iate& ith i$5rease& mor9i&ity a$& morta'ity. Amo$! patie$ts ith ma'i!$a$5y

i$ hom meas'es &e8e'ops, p$emo$itis o55rs i$ = a$& e$5epha'itis i$ 20.

6$emo$ia is the most 5ommo$ 5ase o1 &eath i$ meas'es. It may ma$i1est as

!ia$t 5e'' p$emo$ia 5ase& &ire5t'y 9y the 8ira' i$1e5tio$ or as sperimpose&

 9a5teria' i$1e5tio$. The most 5ommo$ 9a5teria' patho!e$s are Strepto5o55s

 p$emo$iae, 3aemophi's i$1'e$?ae, a$& Staphy'o5o55s ares. 7o''oi$! se8ere

meas'es p$emo$ia, the 1i$a' 5ommo$ pathay to a 1ata' ot5ome is o1te$ the

&e8e'opme$t o1 9ro$5hio'itis o9'itera$s. 5rop, tra5heitis, a$& 9ro$5hio'itis are

5ommo$ 5omp'i5atio$s i$ i$1a$ts a$& to&&'ers ith meas'es. The 5'i$i5a' se8erity o1 

these 5omp'i5atio$s 1re@e$t'y re@ires i$t9atio$ a$& 8e$ti'atory spport $ti' the

i$1e5tio$ reso'8es.

Meas'es i$1e5tio$ is $o$ to sppress si$ test respo$si8e$ess to pri1ie&

t9er5'i$ a$ti!e$. There may 9e a hi!her rate o1 a5ti8atio$ o1 p'mo$aryt9er5'oses i$ pop'atio$s o1 i$&i8i&a's i$1e5te& ith My5o9a5terim t9er5'osis

ho are the$ epose& to meas'es.

Diarrhea a$& 8omiti$! are 5ommo$ symptoms asso5iate& ith a5te meas'es,

a$& &i11se !ia$t 5e'' 1ormatio$ is 1o$& i$ the epithe'im the !astroi$testi$a' tra5t.

Dehy&ratio$ is a 5ommo$ 5o$se@e$5e, espe5ia''y i$ yo$! i$1a$ts a$& 5hi'&re$.

Appe$&i5itis may o55r 1rom o9str5tio$ o1 the appe$&i5ea' 'me$ 9y 'ymphoi&

hyperp'asia.

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7e9ri'e sei?res o55r i$ # o1 5hi'&re$ ith meas'es. E$5epha'itis

1o''oi$! meas'es has 9ee$ a 'o$!asso5iate& 5omp'i5atio$, o1te$ ith a$ $1a8ora9'e

ot5ome. Rates o1 "#)",000 5ases o1 meas'es ha8e 9ee$ reporte&, ith !reater 

$m9ers o55r ri$! i$ a&o'es5e$ts a$& a&'ts tha$ i$ pres5hoo' or s5hoo'a!e&

5hi'&re$. E$5epha'itis is a posti$1e5tios, imm$o'o!i5a''y me&iate& pro5ess a$& is

$ot &e to a &ire5t e11e5t 9y the 8irs. C'i$i5a' o$set 9e!i$s &ri$! the ea$them a$&

ma$i1ests as sei?res +, 'ethar!y 4+, 5oma 2=, a$& irrita9i'ity 2+.

7i$&i$!s i$ 5ere9rospi$a' 1'i& CS7 i$5'&e 'ympho5yti5 p'eo5ytosis i$ = o1 

5ases a$& e'e8ate& protei$ 5o$5e$tratio$. Approimate'y " o1 patie$ts ith

meas'es e$5epha'itis &ie, a$& 2040 s11er 'o$!term se@e'ae, i$5'&i$! me$ta'

retar&atio$, motor &isa9i'ities, a$& &ea1$ess.

Meas'es e$5epha'itis i$ imm$o5ompromise& patie$ts res'ts 1rom &ire5t

&ama!e to the 9rai$ 9y the 8irs. S9a5te meas'es e$5epha'itis ma$i1ests ""0 mo

a1ter meas'es i$ imm$o5ompromise& patie$ts, parti5'ar'y those ith AIDS,

'ymphoreti5'ar ma'i!$a$5ies, a$& imm$osppressio$. Si!$s a$& symptoms i$5'&e

sei?res, myo5'o$s, stpor, a$& 5oma. I$ a&&itio$ to i$tra5e'''ar i$5'sio$s,

a9$&a$t 8ira' $5'eo5apsi&s a$& 8ira' a$ti!e$ are see$ i$ 9rai$ tisse. 6ro!ressi8e

&isease a$& &eath a'most a'ays o55r.

A se8ere 1orm o1 meas'es rare'y see$ $o is hemorrha!i5 meas'es or 9'a5 

meas'es. It ma$i1este& as a hemorrha!i5 si$ erptio$ a$& as o1te$ 1ata'. (eratitis,

appeari$! as m'tip'e p$5tate epithe'ia' 1o5i, reso'8e& ith re5o8ery 1rom the

i$1e5tio$. Throm9o5ytope$ia sometimes o55rre& 1o''oi$! meas'es.

Myo5ar&itis is a rare 5omp'i5atio$ o1 meas'es. Mis5e''a$eos 9a5teria'

i$1e5tio$s ha8e 9ee$ reporte&, i$5'&i$! 9a5teremia, 5e'''itis, a$& toi5 sho5 sy$&rome. Meas'es &ri$! pre!$a$5y has 9ee$ asso5iate& ith hi!h mater$a'

mor9i&ity, 1eta' asta!e a$& sti''9irths, a$& 5o$!e$ita' ma'1ormatio$s i$ # o1 'i8e

 9or$ i$1a$ts.

S9a5te s5'erosi$! pa$e$5epha'itis SS6E is a 5hro$i5 5omp'i5atio$ o1 

meas'es ith a &e'aye& o$set a$& a$ ot5ome that is $ear'y a'ays 1ata'. It appears to

res't 1rom a persiste$t i$1e5tio$ ith a$ a'tere& meas'es 8irs that is har9ore&

i$tra5e'''ar'y i$ the CNS 1or se8era' years. A1ter /"0 years the 8irs appare$t'y

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re!ai$s 8ir'e$5e a$& atta5s the 5e''s i$ the CNS that o11ere& the 8irs prote5tio$.

This s'o 8irs i$1e5tio$ res'ts i$ i$1'ammatio$ a$& 5e'' &eath, 'ea&i$! to a$

i$eora9'e $ero&e!e$erati8e pro5ess.

The patho!e$esis o1 SS6E remai$s e$i!mati5. 7a5tors that seem to 9e

i$8o'8e& i$5'&e &e1e5ti8e meas'es 8irs a$& i$tera5tio$ ith a &e1e5ti8e or immatre

imm$e system. The 8irs iso'ate& 1rom 9rai$ tisse o1 patie$ts ith SS6E is missi$!

" o1 the + str5tra' protei$s, the matri or M protei$. This protei$ is respo$si9'e 1or 

assem9'y, orie$tatio$, a$& a'i!$me$t o1 the 8irs i$ preparatio$ 1or 9&&i$! &ri$!

8ira' rep'i5atio$. Immatre 8irs may 9e a9'e to resi&e, a$& possi9'y propa!ate, ithi$

$ero$a' 5e''s 1or 'o$! perio&s. The 1a5t that most patie$ts ith SS6E ere epose& at

a yo$! a!e s!!ests that imm$e immatrity is i$8o'8e& i$ patho!e$esis. I$

a&&itio$, the i$tra5e'''ar 'o5atio$ o1 the 8irs se@esters it 1rom the imm$e system,

espe5ia''y 1rom hmora' imm$ity.

C'i$i5a' ma$i1estatio$s o1 SS6E 9e!i$ i$si&ios'y /"# years a1ter primary

meas'es i$1e5tio$. S9t'e 5ha$!es i$ 9eha8ior or s5hoo' per1orma$5e appear,

i$5'&i$! irrita9i'ity, re&5e& atte$tio$ spa$, a$& temper ot9rsts. This i$itia' phase

sta!e I may at times 9e misse& 9e5ase o1 9re8ity or mi'&$ess o1 the symptoms.

7e8er, hea&a5he, a$& other si!$s o1 e$5epha'itis are a9se$t. The ha''mar o1 the

se5o$& sta!e is massi8e myo5'o$s, hi5h 5oi$5i&es ith ete$sio$ o1 the

i$1'ammatory pro5ess site to &eeper str5tres i$ the 9rai$, i$5'&i$! the 9asa'

!a$!'ia. I$8o'$tary mo8eme$ts a$& repetiti8e myo5'o$i5 Fers 9e!i$ i$ si$!'e ms5'e

!rops 9t !i8e ay to massi8e spasms a$& Fers i$8o'8i$! 9oth aia' a$&

appe$&i5'ar ms5'es. Co$s5ios$ess is mai$tai$e&. I$ the thir& sta!e, i$8o'$tary

mo8eme$ts &isappear a$& are rep'a5e& 9y 5horeoathetosis, immo9i'ity, &ysto$ia, a$&

'ea& pipe ri!i&ity that res't 1rom &estr5tio$ o1 &eeper 5e$ters i$ the 9asa' !a$!'ia.

Se$sorim &eteriorates i$to &eme$tia, stpor, a$& the$ 5oma. The 1orth sta!e

is 5hara5teri?e& 9y 'oss o1 5riti5a' 5e$ters that spport 9reathi$!, heart rate, a$& 9'oo&

 pressre. Death soo$ e$ses. 6ro!ressio$ thro!h the 5'i$i5a' sta!es may 1o''o

5orses 5hara5teri?e& as a5te, s9a5te, or 5hro$i5 pro!ressi8e.

The &ia!$osis o1 SS6E 5a$ 9e esta9'ishe& thro!h &o5me$tatio$ o1 a

5ompati9'e 5'i$i5a' 5orse a$& at 'east " o1 the 1o''oi$! spporti$! 1i$&i$!s:

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" meas'es a$ti9o&y &ete5te& i$ CS7,

2 5hara5teristi5 e'e5troe$5epha'o!raphi5 1i$&i$!s,

# typi5a' histo'o!i5 1i$&i$!s i$ a$&)or iso'atio$ o1 8irs or 8ira' a$ti!e$ 1rom 9rai$tisse o9tai$e& 9y 9iopsy or postmortem eami$atio$.

CS7 a$a'ysis re8ea's $orma' 5e''s 9t e'e8ate& I!% a$& I!M a$ti9o&y titers i$

&i'tio$s ":=. E'e5troe$5epha'o!raphi5 pat ter$s are $orma' i$ sta!e I, 9t i$ the

myo5'o$i5 phase, sppressio$9rst episo&es are see$ that are 5hara5teristi5 o1 9t $ot

 patho!$omo$i5 1or SS6E. Brai$ 9iopsy is $o 'o$!er roti$e'y i$&i5ate& 1or &ia!$osis

o1 SS6E.

Ma$a!eme$t o1 SS6E is primari'y spporti8e a$& simi'ar to 5are pro8i&e& to

 patie$ts ith other $ero&e!e$erati8e &iseases

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The 5rre$t re5omme$&atio$s i$5'&e a 1irst &ose at mo$ths o'& 1o''oe& 9y a

se5o$& &ose at 24 moths o'& a$& + years o'& 1or meas'es a$& 1irst &ose at " mo$ths

o'& a$& 1o''oe& 9y se5o$& &ose at + years o'&.

A&8erse e8e$ts 1rom the MMR 8a55i$e i$5'&e 1e8er sa''y +"2 &ays

1o''oi$! 8a55i$atio$, rash i$ a9ot o1 8a55i$es, a$&, rare'y, tra$sie$t

throm9o5ytope$ia. Chi'&re$ pro$e to 1e9ri'e sei?res may eperie$5e a$ e8e$t

1o''oi$! 8a55i$atio$, so the riss a$& 9e$e1its o1 8a55i$atio$ sho'& 9e &is5sse&

ith pare$ts. E$5epha'opathy a$& atism ha8e $ot 9ee$ sho$ to patie$ts ith 3I<

ho are $ot se8ere'y imm$o5ompromise& sho'& 9e imm$i?e&. Be5ase meas'es

8irs may sppress the 5ta$eos respo$se to t9er5'os a$ti!e$, si$ testi$! 1or 

t9er5'osis sho'& 9e per1orme& 9e1ore or at the same time as a&mi$istratio$ o1 the

8a55i$e. I$&i8i&a's i$1e5te& ith M. t9er5'osis sho'& 9e re5ei8i$! appropriate

treatme$t at the time o1 a&mi$istratio$ o1 meas'es 8a55i$e.

6osteposre 6rophy'ais

Ss5epti9'e i$&i8i&a's epose& to meas'es may 9e prote5te& 1rom i$1e5tio$

 9y either 8a55i$e a&mi$istratio$ or imm$i?atio$ ith imm$e !'o9'i$. The 8a55i$e

is e11e5ti8e i$ pre8e$tio$ or mo&i1i5atio$ o1 meas'es i1 !i8e$ ithi$ /2 hors o1 

eposre. Imm$e !'o9'i$ may 9e !i8e$ p to + &ays a1ter eposre to pre8e$t or 

mo&i1y i$1e5tio$. Imm$o5ompete$t 5hi'&re$ sho'& re5ei8e 0.2 mL)!

i$trams5'ar'y, a$& imm$o5ompromise& 5hi'&re$ sho'& re5ei8e 0. mL)!

maimm &ose i$ 9oth 5ases is " mL) !. Imm$e !'o9'i$ is i$&i5ate& 1or 

ss5epti9'e hoseho'& 5o$ta5ts o1 meas'es patie$ts, espe5ia''y i$1a$ts + mo$ths o'&,

 pre!$a$t ome$, a$& imm$o5ompromise& perso$s.

6ro!$osis

I$ the ear'y 20th 5e$try, &eaths &e to meas'es 8arie& 9etee$ 2,000 a$&

"0,000, or a9ot "0 &eaths per ",000 5ases o1 meas'es. *ith impro8eme$ts i$ hea'th

5are a$& a$timi5ro9ia' therapy, 9etter $tritio$, a$& &e5rease& 5ro&i$!, the &eathto

5ase ratio 1e'' to ")",000 5ases. I$ 20"4, *3O estimate& that there ere #0 &eaths

5ase& 9y meas'es i$ I$&o$esia, ith a &eathto5ase ratio o1 ".=2.)"00,000 5ases o1 

meas'es. 6$emo$ia a$& e$5epha'itis ere 5omp'i5atio$s i$ most o1 the 1ata' 5ases,a$& imm$o&e1i5ie$5y 5o$&itio$s ere i&e$ti1ie& i$ "4"+ o1 &eaths.

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Re1ere$5es

". ('ie!ma$ RM, Sta$to$ B7, S5hor N7, Behrma$ RE, St.%eme -* 20""

 Ne'so$ Tet9oo o1 6e&iatri5s, "th e&., H$ite& States o1 Ameri5a: E'se8ier 

I$5.

2. (e$$eth To&ar H$i8ersity o1 *is5o$si$Ma&iso$ Departme$t o1 Ba5terio'o!y.

200+. Meas'es. O$'i$e, .9a5t.is5.e&)themi5ro9ia'or'&)Meas'es.Fp!,

A55esse& "2th may 20".

#. Ameri5a$ A5a&emy o1 6e&iatri5s. Meas'es. I$: 6i5eri$! L, Baer C,

(im9er'i$ D, Lo$! S, e&s. Re& Boo: 200 Report o1 the Committee o$

I$1e5tios Diseases. 2=th e&. E' %ro8e