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E10: Measles deep dive

• Mohamed Hagahmed

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Understanding Measles: Recognition, Pathophysiology, and Management in Emergency Settings

Join Dr. Mohamed Hagahmed and Dr. Sylvia Owusu-Ansah in this essential discussion on measles. They cover critical topics such as recognizing measles in emergency settings, understanding its presentation and pathophysiology, and the latest strategies in treatment and prevention. This episode is packed with vital information for healthcare providers, especially in the context of a resurgence in measles cases due to declining immunization rates. Learn about the role of vaccinations, complications like ADEM and SSPE, and the importance of PPE in practice. This conversation is recorded live from the SNMA AMEC conference, addressing both clinical knowledge and public health awareness.

Find pictures of measles rash and how it looks in dark skin individuals in my social media post: https://www.instagram.com/reel/DHLaF4Lxjef/?igsh=Y205enNpeDJzbTM4

00:00 Introduction to Measles
00:41 Current Measles Outbreaks and Concerns
02:03 Understanding Measles Pathophysiology
06:05 Recognizing Measles Symptoms
09:56 Treatment and Prevention Strategies
11:22 Pre-Hospital Care for Measles
16:27 Prophylaxis and Final Thoughts

Mohamed:

Hey folks, welcome to Emerge. I'm your host, Dr. Mohamed Hagahmed, and today we're diving into measles. Joining me is Dr. Sylvia Owusu-Ansah to discuss how to recognize measles in the emergency setting its disease, presentation and pathophysiology, and the latest in treatment and prevention strategies. Stay tuned for a crucial conversation on managing and preventing this infectious disease. Sylvia Owusu-Ansah. I think it's time for me to bring you back here and discuss this important topic that is very relevant. How are you?

Sylvia:

Good. How are you?

Mohamed:

I'm good. I'm glad we are here. I'm kind of like sad also that we're talking about this at the same time.

Sylvia:

A hundred percent. A hundred percent.

Mohamed:

I feel like since the last time we talked. It's been a lot of things happening in the world with children dying from measles and where you and I practice in Pennsylvania, we've been seeing creep up of cases popping in Philadelphia and now in Erie. So I think it's time for us to speak more on that and discuss two aspects of measles identification and care. And maybe some pathophysiology. So what do you think about what's happening and what are your thoughts on that as a pediatric emergency physician?

Sylvia:

Yeah I think it's really sad in the way that measles is very preventable. You know, that's right. Currently, unfortunately measles is making the headlines in Texas, but throughout the United States it is a very highly contagious disease. That is very preventable. And despite there being widespread vaccination, we are still seeing an increase in measles cases because of decline in immunization rates. I think there's a lot we need to do in the way of education and that's what we're gonna talk about today. That's how we're gonna, we're gonna educate our clinicians on the pathophysiology of measles. We're going to talk about recognition of measles treatment and prevention. So let's get into it.

Mohamed:

I like that. So let's discuss pathophysiology. We all know that measles is a virus, so there is no specific antibiotics to combat measles. It's just like the flu.

Sylvia:

Mm-hmm.

Mohamed:

But it has a different way of attacking the immune system. So, can you tell us more about the type of virus that measles is?

Sylvia:

Yes. So measles it's a morbillivirus comes from the Paramyxoviridae, which is related to influenza as you talk about. It usually infects through the respiratory tract mucosal services, and then goes into the lymphoid tissue. And the lymphoid tissue contains a lot of our white blood cells and immune system and then spreads to the bloodstream. So, and that can happen pretty fast and can have significant symptoms.

Mohamed:

So I know that it spreads systemically and it has this specific immunosuppressed properties, right? With measles and that's what basically kills patients, right? Is that the immunosuppression? Yes. And the susceptibility or the high risk of getting co-infections with measles? Yes, that is correct. So can you tell us more about how measles actually suppresses the immune system?

Sylvia:

The lymphoid tissue contains white blood cells, that, and what the white blood cells are, what basically are our immune system. And so it's an RNA, a single-stranded virus that then suppresses parts of the immune system within the lymphoid tissue, not enabling the body to fight infections as it normally does. It also infects through the respiratory tracts. So some of the more common comorbidities are pneumonia. Which again this is pneumonia caused by a virus not caused by a bacteria. So in a lot of ways, this pneumonia may be able to be partially treated by antibiotics, but not fully when it enters the bloodstream, it could also affect the brain and cause what is called ADEM. And that there's really no treatment for, and that can lead to death, that can lead to high mortality once measles affects the brain.

Mohamed:

Let me pause here quickly just to clarify a few things. So measles complications include immunosuppression as Dr. Sylvia Owusu-Ansah mentioned that immunosuppression increases your susceptibility to getting other infection, and that can be from bacteremia pneumonia, which occurs in 6% of cases and has high mortality. That pneumonia can also be from viral pneumonia, which is from the primary measles infection or a bacterial super-infection. She mentioned ADEM. So ADEM stands for acute disseminated encephalomyelitis, which occurs rarely. Typically during recovery with fever, headache, confusion, seizure coma, sensory loss, and para or quadriplegia, and results in up to 20% mortality. There's also another form of encephalitis, and it's called subacute sclerosing panencephalitis also occurs rarely, typically, seven to 10 years following recovery. The symptoms include progressive stage- wise from personality and behavioral changes. That's stage one up to dementia and myoclonus in stage two. And the most severe stage is flaccidity or decorticate posturing, and that's stage three and four. Obviously the worst case scenario is death. Now, back to the show. So let's start from the top. I know we are gonna tackle all of these symptoms and obviously the worst case scenario with brain involvement. The classic measles rash is interesting to me because the virus itself attacks or damages endothelial cells. And that is what's causing this classic rash that we see diffusely and globally starting from the head down to the toes. Right. And this rash has a different kind of presentation in darker skin versus lighter skin. I know the classic, there's a triad, right? First you have the, those prodromal symptoms of measles. I remember them from the board examination, the classic Cs, right? The cough, the coryza, the conjunctivitis. And then I'll also adding the C, which is really not a c, it's a koplik spot. Yep.

Sylvia:

Yeah. Koplik spot. Okay. Yep. So

Mohamed:

the coryza, for those of you who don't know what it means, is basically a runny nose, right? That's the coryza. So the cough, the coryza, the conjunctivitis, and then you see this tiny grain- like, small papule, maybe inside the buccal mucosa. This is the koplik spot that is very specific to measles and it, this is like a pathognomonic, right? For measles. If you find that, then you are a hundred percent sure that this is a measles diagnosis. Now tell me more, a little bit about the rash and how it presents First, where it starts and then how it ends.

Sylvia:

Yeah, so how I learned it it's almost like. If somebody dropped a can of paint on your head, and you can imagine the paint dripping down from head all the way to the toes. So it's very important when you are asking about measles, you wanna ask about how did the rash present? Where did it start? When we talk about people of color it could be a violicious color, meaning like more purplish color. It could be like a scarlatiniform rash that we see in scarlet Fever where it has like these multiple kind of discreet bumps that feel like sandpaper, which may not be typical for other types of ethnic groups where you think about the red measles rash. And so you wanna be careful of that. The rash also helps to indicate where you are as far as being contagious. And so usually in the beginning when you're having those cold like symptoms, your three Cs, your cough, coryza conjunctiva is usually when you're most contagious. And then the rash follows after that. And then you have a little bit of contention after that, but then it falls off. And so measles is very hard and kind of stopping the spread is because when it starts and when it's very contagious, it seems like you have a simple cold, and by the time you have a rash, you may have passed the disease or the virus through airborne transmission onto a lot of people unknowingly.

Mohamed:

So that phase of being asymptomatic is actually deceiving.

Sylvia:

It's very deceiving.

Mohamed:

Yes. So you can really infect a lot of people. Right. So what you're telling me is that because of these different presentations of the rash in different ethnic groups, we have to pay extra attention in darker skin because in darker skin you can literally miss the diagnosis. I mean, I've seen people. Had measles rash, for example, that looked like eczema, right? Yes, yes. I have looked at pictures myself and videos of patients with measles that looked like they had just a bruise. Maybe misdiagnosed as a non-accidental injury. Mm-hmm. Like someone being abused or something like that. So it's very important to look at the picture as a whole, look at those symptoms. Ask the parents whether they had the cough, the conjunctivitis, the runny nose, maybe look, examination wise, look inside the buccal mucosa to look for koplik spots. So now you made the diagnosis. Now what do we do?

Sylvia:

Yeah, no that's a great question. So we know that to not have the disease at all, the MMR vaccine is really where it's at. If you end up having the disease and we know that we've diagnosed with you within 72 hours, we can still give you the MMR vaccine at that point. There has been a lot of talk about vitamin A using vitamin A in younger children, right? We're talking about pediatrics in less age, less than two. Vitamin A can be a little bit helpful, but you have to be very cautious on the amount and it's not a cure all. Remember, this is a virus. Vitamin A is not an antiviral against measles. It may help to alleviate some of the symptoms, but it won't get rid of the virus altogether. For our immunocompromised patients and pregnant women and those that it has been passed the 72 hours, we want to think about measles, immunoglobulin. And so those are some of the things that you can do, but at the bottom line is that prevention is key.

Mohamed:

Absolutely correct, right? We need to focus on prevention with vaccination and identifying these susceptible population that are high risk of getting measles within that fragile community. So we have to educate public health awareness. And then also, you know, combating false information both for you and I as public health clinicians as well. But when it comes, let's say now we found the diagnosis. Let's start from the pre-hospital care now, for those of us who work in the pre-hospital setting, what could they do?

Sylvia:

Yes. So it almost takes us back to the PTSD pandemic that we don't want to talk about, which is covid. Again, like I previously mentioned, this is an airborne transmission. If we remember with Covid, it was an airborne transmission. So PPE is key for measles. PPE is key. So if any pre-hospital provider, EMS clinician suspects so much as suspects, measles, they should put on PPE if possible, if they have an N95 available to them. Put it on the patient and put it on themselves before taking care of the patient, loading the patient. When they are doing, sign out with the hospital, let the hospital know of their concerns so they can put together a negative pressure room potentially for this patient. If it ends up that the patient doesn't have measles, that's okay. The key is to, you know, have preventive awareness to be able to keep everybody safe. Our EMS clinicians safe, our hospital providers safe. Measles is highly contagious. It has an RO of 12 to 18. What does RO mean? RO is the in infectivity of a disease process, meaning that if one infected person has measles, that can spread to 12 to 18 people. And if they're un immunized, they're likely to get that virus. So that can happen pretty quickly. So that could be an EMS clinician, that could be a hospital provider. Anybody could be exposed. So if you suspect measles, think PPE.

Mohamed:

And that's important these days. Obviously as you know, a lot of the paramedics and I must admit to that we tend to slack a little bit, not wear our masks, the regular surgical masks. So I have a feeling that a lot of us maybe, you know, ignore or forget about the PPEs later. So it's important to realize, during these. Specific times where you have, or where you work clinically as a pre hospital clinician in a highly endemic area of measles, just have a PPE with you just in case. So now you are wearing PPE, you know, they have measles, either maybe someone else diagnosed them and now you respond to their house or their location, and they have maybe symptoms of dehydration. So what are some of the pre-hospital interventions, otherwise, beside the mask, anything else they can do?

Sylvia:

So you could still put place in the iv. I would try to do as much sterile procedures as you can to place the iv. I would try to minimize any kind of airway management maneuvers, if you can in the way of intubation, in the way of supraglottic. Anything to having to do with airway. Again, this is an airborne transmitted disease process, if that is avoidable, if the kid is not that sick I would keep to some just basic supportive care with PPE until you can get to the hospital.

Mohamed:

And how about nebulized medications? Albuterol doing nbs, I would

Sylvia:

likely avoid those types of medications unless the, again, the patient is an extremist or critically unstable until you get to the hospital

Mohamed:

and CPAP.

Sylvia:

That as well.

Mohamed:

Okay. But if they need it, obviously they're hypoxic, but Of course. Or course they Or breathing. Exactly, exactly. Obviously. So keep doing things that are indicated for that patient, obviously not unnecessarily. Okay. IV fluid, antiemetics, antipyretics. All supported as we as usual. Now, let's say you mentioned vitamin A briefly, and is vitamin A a benign. Medication.

Sylvia:

No, no medication is benign. Right. And I thought

Mohamed:

Tylenol was benign. Yes, exactly. Or acetaminophen.

Sylvia:

Right. And acetaminophen can kill in an overdose situation, same as vitamin A. Not only can it kill, but there's something called vitamin a toxicity where that can lead to headaches, dizziness, all kinds of eye symptoms, things of that nature. So you wanna be very careful with use of vitamin A. Again, this is not something that's currently regulated in the treatment of measles. It's a suggestion but not regulated.

Mohamed:

So it's important to know that vitamin A is dosed based on age, and the current recommendation is that if the infants is under six months, they should receive 50,000 international units for two days when measles is suspected without ignoring the other intervention that we're already doing. So vitamin A, toxicity, nausea, vomiting, dizziness. Now the worst case scenario with vitamin A toxicity is what is cerebral stuff, right? Yes. So is

Sylvia:

affects your brain.

Mohamed:

So it is increased intracranial pressure and they can become like comatose unconscious. So this is bad stuff.

Sylvia:

Yes.

Mohamed:

Anything else you wanna add to treatment?

Sylvia:

I don't think there's nothing else to add to treatment, but to emphasize the prevention measures and to be careful in the way of PPE doing supportive care. Obviously, if a patient is an extremis, you do the care that you need to do, but do it with caution.

Mohamed:

Okay, so now you have a clinician who treated a child with measles. What type of prophylaxis they have. And I think you alluded to briefly about, prophylaxis with the MMR vaccine. What are the current recommendation now for that?

Sylvia:

I'm gonna back up a little bit. I'm gonna say that in this current day and age with this resurgence of measles cases, it is very important as healthcare providers that we check our titers. So make sure that you either, if you in your EMS agency or in your hospital there should be a method through employee health to check your measles vaccine titers. If you've been vaccinated most healthcare providers need to be vaccinated, so I'll start with that there. If you don't know what your titers are and you are exposed to measles, then within the first 72 hours of exposure you can get an MMR vaccine. If it's past that, then you want to get the measles immunoglobulin. And also if you are immunocompromised or pregnant I would always recommend talking to your doctor about these things as well. But that is the current recommendation. But know what your titers are from the GetGo.

Mohamed:

I like that. So discuss this with your department or your either public health or employee health where you work and trying to find a way of getting the MMR vaccine within 72 hours of exposure. And then of course, this immunoglobulin. Anything else we need to discuss? I feel like we tackled pathophysiology and the course of the infection, the presentation, and then also treatments. Is there anything in terms of you as a pediatric emergency physician that you have encountered in your clinical setting that you think our audience would benefit from?

Sylvia:

Just to remember that measles can also be passed to a fetus in a pregnant woman and could potentially lead to fetal demise. And so it's something to think about on the entire spectrum from measles. So whether you're a baby, an infant, an adult, a pregnant woman a non-immune patient, it can affect us all adversely. So we wanna think about all of our, specifically our vulnerable populations. The other thing to note is that in addition to declining rates of immunizations for measles, don't want people to just get caught up on those who haven't been immunized. There are people who have measles that it's from contact, or they have traveled globally and gotten measles that way. And so know your history. Know whether the patient has recently traveled, know what their immunization status is. In order to prepare yourself to provide the best care for the patient in regards to measles,

Mohamed:

Thank you so much Dr. Sylvia Owusu-Ansah for this very informative session. And just wanna also excuse our audience for the background noise. We're currently speaking from a conference in St. Louis and that's the SNMA or AMEC conference. That's right. AMEC conference. And that's where meeting a lot of future. Physicians and healthcare professionals, and thank you for recording this with me and I hope this was useful to all of you. And please stay compassionate and till next time.