Measles – PediaCast 077
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Topic
- Measles
Guest
Dr. Michelle
Links
- Measles Discussion from KidsHealth
- Measles Article from Mayo Clinic
- Measles Information for Travelers (CDC)
Transcription
Announcer: This is PediaCast.
Dr. Mike Patrick: Bandwidth for PediaCast is provided by Nationwide Children's Hospital. For every child, for every reason.
[Music]
Announcer: Welcome to PediaCast, a pediatric podcast for parents the In Depth Edition. And now, direct from Birdhouse Studios, here is your host Dr. Mike.
Dr. Mike Patrick: Hello everyone. And welcome to PediaCast. A pediatric podcast for moms and dads. This is Dr. Mike coming to you from Birdhouse Studio and I’d like to welcome everyone to the program. It is episode 77, for Tuesday, November 6th,2007. Measles, yup, you heard me right. We are going to talk about a measles today. In fact coming up after the break, Dr. Michelle, our good friend from Hawaii. She is third year family practice resident physician in Hawaii and she’s going to join us to talk about measles. So that will be coming up here shortly.
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I don’t know what is the weather like in your neck of the woods, but, it is a lot chillier and gloomy, and the clouds cover the sun all day long today. And I had mentioned in previous show or two that I really enjoy this time of year. But, now I sort of dread the next stage in our weather cycle. We have these nice sunny fall days and then the clouds roll in and here in Central Ohio it can stay that way for a very long period of time, I laugh about it. But in the midst of it, it really just drives me nuts. So why do I leave here? I don’t know, ‘cause I’m a Buck Eye at heart. I did get the burn pile, I talked about that a little bit yesterday. We got that all taken care of. And I’m glad I did because our yard is just a mess of fallen leaves now. And I’m worried if I waited till next weekend, they would have caught fire. Or I guess I could rake. Are you a raker? We’re not rakers. Just let nature takes it course. Maybe it’s called laziness, I’m not sure.
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All right, don't forget if there is a topic that you would like us to discuss here on PediaCast, all you have to do is go pediacast.org and click on the Contact Link or you can email me at pediacast@gmail.com. Make sure you let us know where you’re from or you can call the voice line at 347-404-KIDS. And that should be up and working. There was a time when the voice line, the Skype line was not working at all. It did not ping because I forgot to pay the bill and now as it turns out the problem is that I paid the bill but apparently there was a new version of Skype. And when I downloaded it all the settings reverted back to their default.
0:03:04.6
And by default, it had it that the answering machine would not pick up. So it would just ring and ring and ring. But I did fix that. So, you can get a hold of me again hopefully by calling the Skype line at 347-404-KIDS. So we should be in business in terms of that. And thanks to my listener in Singapore, you know who you are. I appreciate you Heather giving us the heads up on the fact that the voice line was not working.
OK. Don’t forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child’s health, call your doctor and arrange a face to face interview and hands on physical examination.
Also your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org. And with that mind, we will back with Dr. Michelle and our chat about measles right after this short break.
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Prior to the 1960’s, all kids could expect a break out with the case of the measles some point in childhood. Most kids battle the infection fine, but many did not. And it’s with ease of spread and relatively high complication rate; measles became a prime target for the development of an immunization against it.
0:05:00.8
The first measles vaccine arrived on the market in 1963 with an improved version introduced in 1968. And the combined MMR vaccine which protect against measles, mumps and rubella became available in 1971. Thanks to vaccination, measles outbreaks are rare and isolated events in most parts of the developed world, but the disease still wreaks havoc on unvaccinated population.
According to the World Health Organization, measles is the leading cause of vaccine preventable childhood death, killing more than 100,000 kids in underdeveloped countries throughout the world each year.
And here to join us for a chat about the specifics of measles is our good friend Dr. Michelle from Hawaii.
Dr. Mike Patrick: So welcome back to the program, Dr. Michelle.
Dr. Michelle: Thanks, Dr. Mike.
Dr. Mike Patrick: You have the distinct honor of being very first repeat guest here on PediaCast.
Dr. Michelle: Wow. Thank you.
Dr. Mike Patrick: Isn’t that exciting?
[Laughter]
0:05:58.7
Dr. Mike Patrick: So, we’re going to talk about measles. And when you were here before we talked a little bit about rashes in general. And we talked about their being sort of a classic nomenclature for the childhood disease, isn’t that right?
Dr. Michelle: That’s right. First to six disease.
Dr. Mike Patrick: Right. So we’re going to start with, number one, always a good place to start.
Dr. Michelle: That’s where we like to usually first disease, measles.
Dr. Mike Patrick: Right, Also called Rubeola.
Dr. Michelle: Yes. The old fancy term for it.
Dr. Mike Patrick: Yes. And it’s caused by a virus which is a member of the family…
Dr. Michelle: Paramyxovirus, yeah. It’s Morbillivirus.
Dr. Mike Patrick: There you go.
Dr. Michelle: More fancy words that nobody can ever say.
Dr. Mike Patrick: Right, exactly. But it makes us look smart.
[Laughter]
Dr. Mike Patrick: Now, here is the biggest question I have for you. Have you ever seen a case of the measles?
Dr. Michelle: I fortunately have never seen a case of the measles.
Dr. Mike Patrick: You know, I haven’t either.
Dr. Michelle: Well, that’s a good thing.
0:06:56.8
Dr. Mike Patrick: Yeah, yeah… That’s right. I have several that we thought might be measles when I was a resident. And it always turned out that kind of preyed the medical students through and say “hey, this is what measles looks like”, and there was a reverse isolation room and all that. And then the serology would come back and it was always some other virus.
Dr. Michelle: It does look like a lot of different things, but it’s good, cause even one case in the United States is an outbreak these days.
Dr. Mike Patrick: Right, right. So let’s talk a little bit about measles. In terms of the course of the disease. It can be broken into several components: the incubation, the prodrome, the rash phase, and then recovery. Let’s just talk about each of those here really quickly. So I guess, do you have things to say about the incubation of it?
Dr. Michelle: Actually it incubates for a long time. And that can make it pretty difficult to isolate, the origin of it. So, the incubation period can be anywhere from a week to two weeks. So, 8 days or so before you end up having any symptomology is when you are exposed.
0:08:01.5
Dr. Mike Patrick: Right. And during that time like you said, there is no symptoms at all. So that makes it hard to isolate those people out. Because once they start to have symptoms, you may not know it’s measles yet and they spreading it. That’s one of the reasons they spread so quickly.
Dr. Michelle: Yeah. And actually you are contagious before you develop a symptom as well. You’re not contagious for the whole incubation period though, but, for maybe two to five days before your symptoms start up, then you’re contagious.
Dr. Mike Patrick: Yeah. And that’s scary. So, you really could pass it on and not know… Or you could be exposed to it and not know that that person ever had it.
Dr. Michelle: Absolutely. And actually, because it’s carried in respiratory droplets, you don’t even need to be directly exposed to the person. It’s just could be waiting in the room for you.
Dr. Mike Patrick: Right, or in the shopping cart handle.
Dr. Michelle: Oh yes, lovely.
Dr. Mike Patrick: So, after the incubation period, we talked about there being a prodrome. What is that all about?
0:08:57.6
Dr. Michelle: It’s kind of like cold like symptoms that last a little bit before the rash pops up. So you go a cough and coryza, which is a fancy term for runny nose and kind of conjunctivitis with itchy eyes. You can have a little bit of a fever. Just kind of feeling down trod and then what not. And that kind of happens before the rash pops out.
Dr. Mike Patrick: OK. And how long does that sort of thing usually lasts.
Dr. Michelle: That’s a couple of days. Just kind of like a normal cold would last three maybe five days.
Dr. Mike Patrick: Right. Which makes it even more difficult to know that’s it’s measles because they don’t have the rash yet but they’re very contagious during this stage of it.
Dr. Michelle: Right. And during that stage, sometime they’ll pop out with some Koplik's spots. Any medical students listening will love to hear that term.
Dr. Mike Patrick: Tell us what’s that all about.
Dr. Michelle: Those are kind of our pathognomonic diagnosis for this. They’re small little, maybe a couple of millimeter grayish or bluish kind of spots on the oral mucosa.
0:10:04.0
Dr. Michelle: They’re on a red base and so they kind of… The quote that they give us in medical literature is grains of salt on a red back ground. And that usually occurs shortly before the rash, one to two days before the rash. So sometimes that will occur during the prodrome.
Dr. Mike Patrick: And where exactly, on the inside of the cheeks do you see these?
Dr. Michelle: You can see it anywhere on the buccal mucosa there, but you kind of look where your teeth are.
Dr. Mike Patrick: Right…
Dr. Michelle: Right in the way.
Dr. Mike Patrick: Yes, yes. That’s right. They sort of a classic location of them are across the molars. So, and again these are usually a couple of days before the rash breaks out.
Dr. Michelle: Yes.
Dr. Mike Patrick: OK. So, we have the three C’s. The cough, coryza, and conjunctivitis. And then possibly the Koplik's spots inside the mouth. And then, the rash breaks out, so let’s talk a little about that.
0:11:00.8
Dr. Michelle: Yeah. It’s an erythematous maculopapular rash, which somebody remember last time we talked about a little definition of maculopapular. So, these are raised bumps and they blanch. So, when you touch them they turn whitish. And often they start behind the ears, like at the hairline. And then they spread outward and down.
Dr. Mike Patrick: Right. And this is a distinction of measles compared to some of the other symptom in terms of this pattern of where it starts and how it spreads.
Dr. Michelle: Absolutely, which is one of the many reason why back in our previous talk, we talked about how important it was where the rash starts and where it goes to.
Dr. Mike Patrick: Right. And that we should mention to them the palms and soles of the feet are usually not involved.
Dr. Michelle: That’s correct. Not in typical measles.
Dr. Mike Patrick: Right.
Dr. Michelle: They can be involved in atypical measles.
Dr. Mike Patrick: And this doesn’t seem like it, when we talked about diseases who follows the typical pattern.
0:12:00.3
Dr. Michelle: Exactly. When the patient starts reading the books it will be easier.
Dr. Mike Patrick: Yes. That’s right. That’s exactly right. And then you talked about the lesions becoming sort of confluent especially on the face and the upper part of the body. So that’s something the rash first breaks out a lot of times these lesions will start to all coalesce together. Just make a red area.
Dr. Michelle: Yeah. And then after a couple of days, they were blanching. So they use to turn white then they stop blanching and they come copperish in color and then they go away just after a couple of days.
Dr. Mike Patrick: Yup. So very quick. And then it also sometime followed by a what we call desquamation, where then you basically, you get that copper color, brownish color and then it flakes off.
Dr. Michelle: Yes. Nobody likes that.
Dr. Mike Patrick: Right. And then we have the final stage of measles, which is called the recovery phase. And it’s basically just the cough that can persist for one to two weeks after it, after it’s over.
0:13:03.1
Dr. Mike Patrick: So really, it doesn’t sound so bad. I mean you have… It can spread easily; you got a cold like symptoms. You get these funky spots in the mouth and you get this bad rash and then it’s pretty much gone. So, what’s the big deal?
Dr. Michelle: Yeah, you would think something that goes away on its own wouldn’t be a big deal. But, the big deal is that it can cause lots of morbidity and mortality because it mostly affects young ones. So, in our country, in the US, it mostly affect those less than two years old because of immunization. And they’re of course the ones without the ability to fight off infections.
Dr. Mike Patrick: Right. And we’re kind of cheating here a little bit, the main thing is that there are a lot complications that can be associated with this.
Dr. Michelle: Absolutely. Up to 25% those who get it can get complications actually.
Dr. Mike Patrick: Yes. So that, I mean that’s the big thing. The primary viral exanthem and infection part of it, not too big of a deal. It’s these complications that are the real issue. So let’s talk about some of those.
0:14:07.9
Dr. Michelle: Sure, it disseminates. The virus goes to every system in your body. So, basically there can be complications anywhere. But some big ones include, there’s hemorrhagic lesions of the skin and bowel. Some people may have heard of black measles. The black dots in the bowel or in the skin. You can actually get heart manifestations in myocarditis or pericarditis. But, those are some of the big ones. But the biggest two are neurologic.
Dr. Mike Patrick: Right. So let’s talk a little bit about those.
Dr. Michelle: Sure. There’s post infectious encephalomyelitis.
Dr. Mike Patrick: That’s a big word.
Dr. Michelle: That’s just another big fancy word. And it’s abbreviated, unfortunately PIE. But, this usually occurs within a couple of weeks of a different rash. And it’s not due to the virus itself, it’s due to the body’s response. So it’s an autoimmune response to the virus.
0:15:06.8
Dr. Mike Patrick: OK. And what exactly is happening to the nervous system with this?
Dr. Michelle: Well, the nervous system gets a little confused. And kind of goes after itself. And you end up getting symptoms similar, kind of similar to other infections of the nervous system.
Dr. Mike Patrick: Right. So you can have a headache, a delirium, lethargy, seizures, coma, all these things. Even paralysis can be seen with it too.
Dr. Michelle: Absolutely. Paraplegia, loss of control of your bowel bladder. All of those kind of things.
Dr. Mike Patrick: It kind of reminds you of Guillain–Barré, a little bit. And we've actually discussed that in past episodes of PediaCast. So, the avid listener will know what I’m talking about. But it’s another autoimmune type issue with the central nervous system. So, it’s a bad thing, that’s the bottom line.
0:16:02.4
Dr. Michelle: It is. It has a 20% mortality. And even the survivors, all the survivors have residual neurologic abnormalities. Some relatively minor like behavior disorders. But it can include epilepsy or mental retardation from that.
Dr. Mike Patrick: And then there’s this interesting, I say interesting from the my science point of view, from the human impact of it, it’s not too interesting. The subacute sclerosing panencephalitis, I think it’s the other neurological issue you were talking about.
Dr. Michelle: Absolutely.
Dr. Mike Patrick: Yeah. So this is something that happens years after the initial infection.
Dr. Michelle: About a decade after it.
Dr. Mike Patrick: Yeah, yeah. And what happened with this one?
Dr. Michelle: This is a progressively fatal degenerative disease of the nervous system. They don’t really understand how it’s affecting the neurological system. But they think it’s possibly a genetic variant of the measles virus. And it is invariably fatal.
0:17:03.7
Dr. Mike Patrick: Right. So, this one isn’t the immune system attacking the central nervous system. They think it’s actually a variant virus that just persistently infecting the central nervous system.
Dr. Michelle: That’s correct. And there are four stages that the nervous system goes through. And it just gets progressively worse until unfortunately death occurs.
Dr. Mike Patrick: Yep. Definitely a good reason not to get measles. So,…
Dr. Michelle: Yes. One of the reasons on my list, yes.
Dr. Mike Patrick: Yes, yes, yes. And then, another complication that we didn’t talked about at all is also probably the most common would be pneumonia. So you can get a secondary bacterial pneumonia along with measles as well. And then on my list I have also cornea ulceration can happen with measles. So in the eyes can be become affected
Dr. Michelle: You can have keratitis leading to blindness too.
0:18:00.2
Dr. Mike Patrick: Yeah, and hepatitis and even appendicitis.
Dr. Michelle: Appendicitis, isn’t that weird?
Dr. Mike Patrick: Yeah, it is weird. So, definitely measles is something we want to avoid and that is why we make such a big deal about making sure that kids have vaccinations against it. Now, we talked a little bit about some of the other things. And we have both mentioned that we have never actually seen measles before. Although, I do have a couple of partners who are old enough that they actually had measles when they were kids. So they definitely seen it. But what are some of the other diseases that kind of can mimic measles that we have to think about.
Dr. Michelle: Oh, it can pretty much look like anything that is going to be a viral symptom. It can totally look like mono, if you give a mono patient amoxicillin, then they can develop a rash similar. Any sort of drug eruption or allergic reaction, micro plasma, German measles. There’s so many different things it can look like.
0:19:01.4
Dr. Mike Patrick: Yeah. Scarlet fever….
Dr. Michelle: Oh, absolutely.
Dr. Mike Patrick: Toxic shock syndrome is on the list too. And another one that we talked about recently was Kawasaki disease. And that one some kind on the list to think about as well.
Dr. Michelle: Yes.
Dr. Mike Patrick: All right, if you have a kid who has this sort of clinical… They have all of these things happening that we’ve talked about and you think it might be measles, as doctors, what do we do then to diagnose it.
Dr. Michelle: Well actually it’s a clinical diagnosis. But, nowadays we do serology testing as well because we have to report any sort of, any cases, because like what I said before, one case is considered an outbreak in the United States. So we usually test for IgM which is Immunoglobulin M, or we can also check for immunoglobulin G as well.
Dr. Mike Patrick: Right. And so, the G one is also going to be positive just from having the immunization too, correct?
Dr. Michelle: That’s correct.
0:19:57.3
Dr. Mike Patrick: Right. And then there… this is, we do have some medical students who listen and some nurse. So I’m going to go just a little bit farther. There is this something called acute and convalescent titers. And the reason those helps if you remember, when you get the vaccine or if you had a measles infection a long time ago, your IgG is going to be positive but there is a subset of people that will have both IgM and IgG positive from the vaccine, that lingers. And so if you get IgG and IgM during the illness and the M is high and the G is high. And then a few months later you check it again and now the M is low, then you can look retrospectively and say “oops, it was probably measles”. That’s PediaCast pro.
OK. So you diagnose someone with measles what do you do to treat them?
Dr. Michelle: Well, mostly it just symptomatic treatment, outpatient. Unless there are complications. So, basically with any viral illness, we try and make the child comfortable. Keep the fever down, hope help their cough, give them lots of fluids, rest and TLC.
0:21:06.9
Dr. Mike Patrick: Yup. So just supportive and then try to anticipate complications and be on the look out since the complication rate is so high. And then obviously, vaccines are going to be the biggest way to prevent it. But there’s also this concept of herd immunity. And why don’t you talk about that a little bit. What is that all about.
Dr. Michelle: The concept of herd immunity is that, basically that everybody else is getting vaccinated, so I don’t need to because I can’t get it because nobody else can. Which unfortunately isn’t very true. We’ve had some outbreaks here in the US in the past five to ten years because somebody from travel abroad and brought it back.
Dr. Mike Patrick: Right, right. And I guess from my point of view the herd immunity thing is important just in terms of the vaccine is not 100% effective in every person. So even if you…
Dr. Michelle: That’s correct.
Dr. Mike Patrick: So if you get the vaccine, you might be a non-responder to the vaccine, but you are relying on herd immunity to some degree, so.
0:22:06.7
Dr. Michelle: Absolutely, there is a 99% immunity with two doses of the vaccination. If the first dose is given after 12 months of age.
Dr. Mike Patrick: Right.
Dr. Michelle: But still, there is that 1%.
Dr. Mike Patrick: That’s right. And you take thousands of kids and there’s a handful , so…
Dr. Michelle: That’s right.
Dr. Mike Patrick: I do have some links in the Show Notes. I have a measles discussion that’s pretty basic from kidshealth.org and then we also have a more advance measles article from the Mayo Clinic. And I found a really interesting one from the CDC, it’s Measles Information for Travelers. So, we’ll put a link to all three of those in the Show Notes. If any of you are interested in learning more about measles on your own, then you can. So, well thank you Dr. Michelle for stopping by. I really appreciate it.
Dr. Michelle: Thank you, Dr. Mike. It’s always fun.
Dr. Mike Patrick: And you’re going to be back in another month or so and what’s the childhood exanthem number two?
0:23:02.6
Dr. Michelle: We are going to talk about, let me see, is it rubeola?
Dr. Mike Patrick: Rubeola, excellent. Rubeola, wait a minute.
Dr. Michelle: Wait, I have to think about it. You made me think about it too hard.
Dr. Mike Patrick: I’m sorry. Rubeola is measles. That’s the one we are doing now.
Dr. Michelle: Oops, rubella.
Dr. Mike Patrick: Rubella, so German measles, OK.
Dr. Michelle: There we go.
Dr. Mike Patrick: So we are going to talk about German measles.
Dr. Michelle: Yup, German measles, I got confused. Oh, you know what, that’s third disease. We’re sounding silly. Second disease is Scarlet fever.
Dr. Mike Patrick: You know, at the back of my mind I thought that. See, doctors have to write down notes too…
Dr. Michelle: This is why we don’t use numbers.
Dr. Mike Patrick: Yes, exactly. OK, so Scarlet fever will be next and then rubella will be on down the road.
Dr. Michelle: That’s right.
Dr. Mike Patrick: OK. So, we’ll look forward to it and I understand you have a little bit of a cold or under the weather, so, take care of yourself.
Dr. Michelle: Thanks. But not the measles stuff.
Dr. Mike Patrick: OK, good, good. We’ll talk later. Bye bye.
Dr. Michelle: Take care, Dr. Mike.
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0:24:00.3
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Dr. Mike Patrick: All right, very quickly. Thanks go out to Dr. Michelle, for joining us again to talk about measles. And stay tune because she will be back again in the future to talk about another infectious disease, so that should be fun and interesting. Also thanks go out to Nationwide Children’s Hospital for providing the bandwidth for our program. Also Vlad over at vladstudio.com for contributing the artwork and make sure that you do support Vlad again that’s at vladstudio.com. Thanks to all of you for tuning in and choosing PediaCast out of the myriad number of other podcast that you could otherwise be listening to. So we really do appreciate you taking the time out of your busy day to let us be a part of it.
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Tomorrow, we have a Listener’s Edition coming up, so we have a bunch of your questions we’re going to answer and until then, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long everybody.
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