Authors         
B.K.Brar, Neerja Puri ,BB Mahajan
Department of Dermatology & Venereology,
Govt GGS Medical College & Hospital,             
Faridkot (INDIA) 151203

Address Correspondence     
c/o Brar eye Hospital, Faridkot Road,  Kotkopura. Punjab.

Sir,

            Measles (rubeola) is a highly contagious, acute exanthematous respiratory disease with a characteristic clinical feature and pathognomic enanthem.¹ Patients with impaired cell mediated immunity are at especially high risk for severe or even fatal measles.² Measles virus is transmitted by respiratory secretions, predominantly through exposure to aerosols but also through direct contact with large droplets. Patients are contagious from 1-2 days before the onset of symptoms until 4 days after the appearance of the rash. Infectivity peaks during the prodromal phase.

Case report

         A 5month old child was brought to the department of dermatology by his mother with moderate fever, watery rhinorrhoea (Fig 1), watering from eyelids and papular rash.

         On cutaneous examination, papular erythematous non pruritic, maculopapaular rash was present all over the body including face, behind the ears (Fig 2), trunk (Fig 3) and limbs. Kopliks spots were present on the buccal mucosa. The patient had history of exposure to measles . His elder sister was suffering from measles at the same time. No vaccination was given to the child.

         The Ig M antibodies (which are specific for measles) were slightly raised

(10.2 units) and  Ig G antibodies were moderately raised (16.8 units). Patient was clinically diagnosed as a case of measles because of Koplik spots, rash and measles antibodies.

Discussion

         A specific diagnosis of measles can be made quickly by immunofluorescent staining of a smear of respiratory secretions for measles antigen; monoclonal antibodies conjugated to fluorescin are commercially available for the purpose.⁴ Secretions can also be examined microscopically for multinucleated giant cells. Among the serological tests, enzyme immunoassay (EIA) is usually done as it is more sensitive and simpler to perform^,5,6 EIA can be used to measure specific Ig M and thus to diagnose measles on the basis of an acute phase serum sample alone. Specific Ig M antibodies are detectable within 1-2 days after the appearance of the rash and the Ig G titres rise significantly after 10 days. ⁷

         Children who are susceptible to measles and are exposed to the disease should receive post exposure prophylaxis.⁸

         The dose of standard immune globulin is 0.25 ml/kg for normal healthy persons. Immune globulin is particularly strongly indicated for susceptible household contacts, especially those less than 1 year of age and for immunocompromised persons.  Vaccination within 72 hours of exposure may also provide protection against clinical measles, but this strategy is contraindicated as post exposure prophylaxis for immunocompromised persons.⁹ Vaccine and immunoglobulin should not be given concurrently.

         This case is reported as measles below 6 months of age is rare. Also, if there is an epidemic of measles, the  infants can be protected by giving standard immunoglobulin, given intramuscularly within 6 days of exposure. It can exert a protective or modifying effect; the earlier it is given, the better the outcome.

         So, we conclude, that although measles is rare before six months, but any infant exposed to measles in a community should be given immunoglobulin to prevent the episode of measles. As we don't recommend  measles vaccination before nine months , all healthy contacts can be given immunoglobulins. 

References

1.     Fraser KB, Martin SJ. Measles virus and its biology : Academic press, 1978.

2.     Kaplan LJ etal : Severe measles in immunocompromised patients. JAMA. 267 : 1237, 1992.

3.     Janeway CA, gitlin D : the gamma globulins. Adv pediatr.9 : 65, 1957.

4.     Sunason MF etal : Diagnosis of measles by fluorescent antibody and culture of nasopharyngeal secretions. J Viral Methods. 33 : 223, 1991.

5.     National vaccine advisory committee : The measles epidemic, barriers and recommendations. JAMA. 266 : 1574, 1991.

6.     Editorial : Immunology of measles. Lancet 1989, II : 781-81

7.     Rauh LW, Schmidt R : Measles immunization with killed virus vaccine. Serum antibody titres and experience with exposure to measles epidemic. Am J Dis Child 109; 232 , 1965.

8.     Linneman CC. Measles vaccine : Immunity, reinfection and revaccination. Am J Epidemiol 1973;97 :365-71.

9.     Markowitz LE, Orenstein WA. Measles vaccine. Pediatr Clin North Am 37: 603, 1990.

LEGENDS TO PHOTOGRAPHS

FIG 1. 5 month old child with watery rhinorrhoea along with rash.

FIG 2. Maculopapular rash behind the ears and back of neck.

FIG 3. Maculopapular rash over the chest and abdomen.