The Diagnosis, Signs and Symptoms of the Measles

Measles have been prevalent in recent times, despite the eradication of the disease because of the mandated vaccination. Statistics have shown that “as of April 26, 2019, The Center of Disease Control and Prevention (CDC) had reported seven hundred and four (704) cases of measles in the United States since the beginning of 2019, which represent the largest number of cases reported in the country in a single year since 1994, when nine hundred and sixty three (963) cases occurred, since measles was declared eliminated in 2000” (Patel et al., 2019). Clinically, Measles is a highly contagious viral disease with serious potential complications and even death. Its mode of transmission is “oropharyngeal; susceptible individuals exposed to an infected person who is coughing and sneezing” (Alspach, 2015).

After the virus invades the body, it first starts in the respiratory system and there is replication in the nasopharynx and regional lymph nodes. The disease has four clinical stages: “incubation, prodromal, exanthema (rash) and recovery. Symptoms associated with the prodromal phase normally begin about ten days after exposure to the virus” (Bentley, Rouse, & Pinfield, 2014). In addition, the incubation period of measles “from exposure to prodromal, averages 10–12 days and then from exposure to rash onset averages 14 days (range, 7–21 days)” [The Centers for Disease Control and Prevention (CDC, 2019).

Measles signs and symptoms are “stepwise increase in fever to 103°F–105°F which happens in the prodromal phase” (Bentley et al. 2014) followed by cough, coryza (acute inflammation of the mucous membrane in the nose), conjunctivitis. Koplik spots (rash on mucous membranes), show 14 days after exposure in the exanthema (rash) stage (CDC, 2019); it persists for 5-6 days which first begins to appear on face and upper neck, maculopapular (flat or raised red bump on skin becomes confluent and then fades in order of appearance. “The rash fades gradually in the same order as it appeared and leaves a brownish discoloration, sometimes finishing with a fine desquamation” (Bentley et al. 2014). In the recovery phase, according to Bentley et. Al (2014), clinical improvement can be seen 48 hours after the rash appears in the absence of complications, although cough may last for several hours.

Demographics of people with measles more likely to get the complications include “children younger than 5 years, adults over 20 years, pregnant women, and anyone with compromised immune status” (Alspach, 2015). Statistics based on 1985-1992 surveillance data show that for measles complications, diarrhea was reported in 8% of measles cases, making this the most commonly reported complication of measles, including Otitis media 7%, Pneumonia 6%, Encephalitis 0.1%, Seizures 0.6-0.7%, and death 0.2% (CDC, 2019). In addition, rare complications of measles according to Bentley et al. (2014) include encephalitis, with Subacute Sclerosing Panencephalitis (SSPE) occurring in about one in 25,000 people infected by measles. SSPE is a progressive neurological disorder caused by persistent measles virus infection. Initial symptoms typically occur some years after natural measles infection and are initially subtle, with intellectual decline and behavioral changes which may only be recognized as symptoms in retrospect.

Regarding treatment, there is no specific cure for an established measles due to its biological agent which is virus. It is advisable for the disease to run its course while the symptoms are being managed for comfort as soon as it is felt. It is recommended, according to Alspach (2015), to rest for fatigue or malaise, use warm water sponge baths and mild antipyretics for fever, drink fluids (preferably water) to avoid dehydration and keep to hydrated and use humidifier or vaporizer for cough. For pregnant people infected with the virus, “Immune globulin is a recommended prophylaxis for non-immune, exposed obstetric patients as long as treatment is received no more than six days after exposure. Immune globulin is administered intramuscularly at 0.25 ml/kg (maximum dose = 15 ml; given at two injection sites). It will not prevent measles but may suppress the measles-induced symptoms until the MMR vaccination can be administered upon completion or termination of pregnancy. The immune globin may positively affect the neonate by the reducing the risk of developing measles if the maternal infection is close to parturition” (White, Boldt, Holditch, Poland, Jacobson, 2012).

As a healthcare provider, if signs and symptoms of measles are observed in a facility, patient should immediately be isolated to avoid airborne transmission. These isolation procedures should be taken according to the Centers for Disease Control and Prevention, “follow respiratory etiquette and airborne precautions, use respiratory protection and follow airborne infection control precautions. Despite the low likelihood of MMR vaccine failure, all staff who provide care to infected patients need to follow airborne precautions, preferred placement for measles patients is in a single-patient airborne infection isolation room, Quickly report the case to the local health department, and at first contact with suspected cases, obtain the following laboratory samples for diagnosis and genotyping: serum, throat (or nasopharyngeal) swab, urine, and viral specimens”.

A laboratory test is needed to accurately diagnose the viral infection (measles) in the blood. A laboratory test for measles diagnosis is the measles RNA by Real-Time Polymerase Chain Reaction (RT-PCR) detection in swab samples (CDC, 2019) and IgG and IgM antibodies detected in serum samples obtained. Two serum specimens which can isolated from urine, nasopharyngeal aspirates, heparinized blood, or throat swabs to test for IgG antibody (CDC, 2019). The IgG antibodies are detected in the blood when there is an immune reaction to a viral or bacterial infection. To further confirm the measles diagnosis, a second specimen is obtained. As a result, IgM antibodies detected will further confirm the diagnosis of measles. IgM antibodies rise in the blood as the first initial reaction to infection.

By definition, “the sensitivity of a test is defined as the ability of the test to identify correctly those who have the disease while the specificity of the test is defined as the ability of the test to identify correctly those who do not have the disease” (Celentano, Szklo, & Gordis, 2019). To test the sensitivity and specificity of each test 3 cohorts were gotten for the study. According to Van Binnendijk, et al. (2003), to analyze different diagnostic tests, serum samples like blood fluid, swab from throat, oral fluid, and urine specimens were gotten from one hundred and one people (n=101) within two weeks after the first measles report (this is cohort 1). For Cohort 2, specimens were gotten from patients with undiagnosed measles cases who presented to a different city health center during the epidemic. Data are presented for ninety three people from whom oral fluid, throat swab, and urine specimens were gotten (n=93). Cohort 3 (controls) includes oral fluid specimens gotten from healthy adult persons (n=65), from patients with confirmed rubella or parvovirus B19 infection (n=13), and from patients who had a recent visit to their primary care physicians (PCP) for acute respiratory illness (n=116).

In the diagnostic test of the detection of IgG and IgM antibodies in cohort 1 and 2, specimen collected from people (n=25) and after (n=27) the onset of measles rash and from people who were exposed but did not develop clinical symptoms (mainly the parents and older household members; n=49). Of 57 specimens collected after the onset of rash (cohorts 1 and 2), 49 were IgM positive and 8 were IgM negative. For cohort 3 (control group), significant change of the specific IgG and virus-neutralizing antibody response was observed in 8 of 33 investigated healthy contact persons. Three of these people had Measles Virus-specific IgM antibodies present either in serum (subjects 8 and 10) or in oral fluid (subject 2). Of interest, Measles Virus RNA was seen in the oral fluid specimen from subject 2. Measles Virus RNA was also detected in the oropharyngeal specimens from 2 other persons (subjects 1 and 3). One of these people (subject 1) had Measles Virus-specific IgM antibodies in serum and in oral fluid, whereas the other person (subject 3) had remarkably high titers of Measles Virus-specific serum IgG and virus-neutralizing antibodies, compared with the remainder of the investigated persons (table 2, subjects 13–33). Another person (subject 11) also showed high titers of specific serum IgG antibodies, but this person’s specimens did not yield positive test results in the other assays.

However, in the diagnostic test of Real-Time Polymerase Chain Reaction (RT-PCR) detection in samples, there is a detection of the presence of Measles Virus-specific RNA in oral-fluid specimens (n=53) and in throat-swab specimens (n=80), as quantitatively determined by real-time RT-PCR and in urine (n=71), as qualitatively determined by nested RT-PCR. Viral RNA was detected in all 3 specimen types as early as 5 days before the onset of rash and as late as 12 days after the onset of rash. Although the levels of specific RNA in individual oral-fluid specimens varied to a large extent, a clear increase and decrease of virus load was observed in individual throat swabs, with RNA concentrations peaking near the day of the onset of rash. Viral RNA was detected in 11 of 14 urine specimens obtained 2–5 weeks after the onset of rash. Viral RNA also was also detected in the oropharyngeal specimens from 3 persons within the group of healthy contacts. This was not observed in any of the oropharyngeal specimens obtained from unexposed persons. For sensitivity and specificity, the combined detection of viral RNA and MV-specific IgM antibody in oral fluid appears to provide high sensitivity and specificity for measles diagnosis. There is early detection of the measles virus in throat-swab specimens as early as 5 days before and as late as 12 days after the onset of rash, with peak concentrations occurring near the first day of rash.

In conclusion, the best laboratory test for measles diagnosis is Real-Time Polymerase Chain Reaction (RT-PCR). “The data from the study indicates that RT-PCR reaches a sensitivity and positive predictive value close to 100% when applied to at least 2 clinical specimens (e.g., throat swab and urine specimens). RT-PCR–based detection of the virus also proved to be specific and independent of the development of clinical symptoms” (Van Binnendijk, et al, 2003).