vaccine-preventable disease; immigrant population
Is This Rash Measles?
Sandy Hoar, DSMc(c), LSHTM, PA-C
A patient presents to a Maryland clinic complaining of a dry red, bleeding, crusting, painful, non-itchy rash which started on her right forearm, 3-1/2 days ago. It spread to the trunk, face and thighs. The patient is complaining of fatigue, bilateral eye and mastoid pain, frontal headache, sore scalp, and bone pain. She reported no exposure, or travel but does have contact with children. She had childhood measles and chickenpox. The patient had tried oral tetracycline. The patient had discrete, mostly papular lesions on the upper arms, trunk, face/neck, and thighs. No lesions on palms/lower extremities. Scalp was tender but without lesions. No conjunctivitis or light sensitivity, left tympanic membrane dusky, nose occluded, no sinus tenderness. No lymphadenopathy. Tongue was coated, single raised soft palate red lesion, no tonsillar enlargement.
This had elements of measles but looked like chickenpox. I doubted rocky mountain spotted fever/ehrlichiosis or CMV/EBV but checked RPR, HIV, an ASO titer, and IgM/IgG for rubella, rubeola, and varicella. Varicella IgM titer was positive, rubeola equivocal. There was mild leukocytosis with atypical lymph. Repeat Rubeola was negative, lesions gone, and I cleared the patient for work. I saw another patient with healing chickenpox a week later.
Measles is a very contagious respiratory infection. The measles vaccine has drastically reduced measles morbidity and mortality. Measles was declared eliminated from the US in 2000 but 23 states have reported 764 measles cases from January to May 2019, including 5 cases in Maryland. Chickenpox also is a very contagious disease. The virus can settle up to tens of meters away, carried on air currents. It produces an itchy rash with blisters that start on the chest, back, face, then spread. All stages of lesions are typically present together; macular, papular, vesicular, crusting. Exposure to varicella after recover may lead to breakthrough varicella, usually with fewer maculopapular lesions. Varicella was very significant before the US vaccine in 1995.
Hospitals and clinics establish plans for known infections, e.g. ebola, but they also maybe the first to see vaccine-preventable infections. The recommended vaccine is a combination of measles, mumps, rubella, and varicella (MMRV). One of these emerging may herald the others. Chickenpox is not required to be reported in Maryland but clinicians should watch for MMRV-preventable infections and report cases, even if not required.