Transcript Measles and Neonatal Tetanus

Measles
Measlesand
andNeonatal
NeonatalTetanus:
Tetanus:
Clinical
ClinicalSigns
Signsand
andTreatment
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.
Measles: Basic Characteristics
Also known as “dadura”/”bhosa kai” / rubeola /
fourth day disease/ first fever
Acute viral illness
Primarily affects children
Highly contagious
Paramyxovirus
– RNA, single stranded
Vaccine preventable
– Potential to be eliminated
Measles: Signs and Symptoms
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
Koplik’s spots
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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
Rash
Hairline
Behind Ears
Erythematous papular
eruption
Face
Travels inferior over 2-3
days
Trunk
Coalesces into macular
“splotches”
Limbs
Often desquamates at end
of illness
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
week)
– Complete recovery in 10-14 days
Summary: Diagnosis / Clinical
Clinical illness includes all of
the following symptoms:
– Temperature of 38.3°C or
more.
– Cough, coryza or conjunctivitis
– Generalized maculopapular
rash for at least three days
following temperature and
cough, coryza or conjunctivitis.
Koplik’s spots can be classic,
but easily missed
Measles
Dengue
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:
Five years , child
– 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 molars.
On fourth day
– 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.
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
Subacute Sclerosing Panencephalitis–SSPE
– 2-15 years after infection
– Progressive behavioral changes
Secondary infections: Pneumonia; flaring of
tuberculosis.
Myocarditis
Corneal ulcer
Measles: Prognosis
Mortality varies by age / nutritional status
– Historically 1-5%
Higher with close contact secondary cases from
presumed high viral exposure
– West Africa/Asia: 25%
– Death: pneumonia, malnutrition, diarrhea
Risk factors
– Immune compromise, Vitamin A deficiency
Measles: Treatment
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*
Vit-A 
Age
0–5
Months
6 – 11
Months
>12
Months
Initial Dose
50,000 IU / day
X 2 days
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
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
within one year.
Measles: Prevention
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
for vaccine, active TB, leukemia, known HIV
– Impractical for developing world
Measles: Prevention
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,
pregnancy, anaphylaxis to neomycin or gelatin
Most recommend vaccinating HIV patients
Measles: Prevention
Vitamin A
– National Vit. A programme
– Targets children >= 6
months old
– Decrease mortality by
improving nutrition
– Benefit likely involves
many infections, but
measles is at the top
Neonatal Tetanus
First described by Hippocrates
Etiology discovered by Carle and Rattone
in 1984
Passive immunity used for treatment and
prophylaxis during World War I
Tetanus toxoid first widely used during
World War II
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 spasm.
Clinical Features
Incubation period: 8 days (3-21 days).
Three clinical forms:
–Local (not common)
–Cephalilc (rare)
–Generalised most common
Descending symptoms of trismus, difficulty
swallowing, muscle rigidity and spasm.
Spasm continues ( consciousness
retained)
Neonatal tetanus
A conscious spasm
Tetanus: complications
Laryngospasm
Hypoglycemia
Nosocomial infections
Myoglobinuria
Aspiration
Iatrogenic apnoea
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
intravenously.
– Dantrolene; chlorpromazine; baclofen
– Vecuronium and pancuronium with
Mechanical ventilation (best survival rate)
Management: contd.
IV line.
Nasogastric tube feeding.
Minimal handling.
A separate room.
Prevention
An entirely preventable disease
– Mortality <10% (intensive care treatment)
> 70% without intensive care treatment.
Antenatal Tetanus Toxoid
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