Divine Word Hospital

Tacloban City, Leyte

Department of Pediatrics

SGD Guide Questions

PGI CORDA, HERMILEEN LACSAMANA Date: April

11, 2024

Question #1: Give the salient features for this patient.

 11 month old
 Male
 Intermittent moderate to high grade fever
 Cough
 Profuse nasal secretions
 Significant decrease in appetite
 Irritability
 Bilateral conjunctival redness with yellowish eye discharge
 Erythematous rashes initially on the forehead extending along the hairline to behind the ears,
face, neck and spreading downward to the chest
 Incomplete vaccination for age
 PE
o Ill-looking, irritable
o Febrile at 39.5
o (+) Erythematous maculopapular rash on face, neck, chest and arms
o (+) Erythematous bulbar and palpebral conjunctiva with yellowish eye discharge
o (+) Matte eyelids OU
o (+) Small 1mm white papules in clumps over the buccal mucosa
o (+) Watery nasal discharge
o (+) Cervical lymphadenopathy, <0.5 cm non tender cervical lymph nodes

Question #2: Give the most likely diagnosis & basis for diagnosis.

Diagnosis: Measles
Basis for diagnosis Reference
5 days history
 (+) Intermittent
moderate to high
grade fever
 (+) Cough
 (+) Profuse nasal
secretions (Coryza)
 (+) Bilateral
conjunctival redness
with yellowish eye
discharge
  (+) Small 1mm white
papules in clumps
over the buccal
mucosa

 Erythematous rashes
initially on the
forehead extending
along the hairline to
behind the ears, face,
neck and spreading
downward to the
chest

 Palpable small <0.5

cm nontender
cervical lymph nodes

Question #3: Give relevant differential diagnoses & state how they can be ruled out.

KAWASAKI DISEASE
Rule in Rule out
 
RUBELLA
Rule in Rule out
 
DENGUE FEVER
Rule in Rule out
 

Question 4: Give the initial work-ups & expected findings.

The diagnosis of measles is almost always based on clinical and epidemiological findings.
Laboratory findings in the acute phase include:
1. Complete blood cell count
 Decreased white blood cell count
 Lymphocytes decreased more than neutrophils
2. CRP
 Normal – if not complicated with bacterial infection
3. Erythrocyte sedimentation rate
 Normal – if not complicated with bacterial infection
4. Chest Xray

Question 5: Give the therapeutic management for Lucas addressing the problems identified.

Management of measles is supportive because there is no specific antiviral therapy approved for
treatment of measles.

Goals of therapy:
1. Maintenance of hydration
2. Oxygenation
3. Comfort

I. Supportive Care
 Maintenance of good hydration and replacement of fluids lost through diarrhea or
vomiting
o IV rehydration may be necessary for severe dehydration
o Affected patients may be highly febrile and consequently become dehydrated
 Continue breastfeeding and continue feeding for older infants and children
 Antipyretics for fever at 10-15 mg/kg/dose given every 4 hours for fever.
o Paracetamol
 Airborne precautions for hospitalized children during the period of communicability, 4 days
before to 4 days after the appearance of the rash in healthy children and for the duration of
illness in immunocompromised patients.
II. Vitamin A supplementation
 Vitamin A therapy is indicated for all patients with measles
 Vitamin A should be administered once daily for 2 days at doses of
o 200,000 IU for children 12 mo of age or older;
o 100,000 IU for infants 6 mo through 11 mo of age;
o and 50,000 IU for infants younger than 6 mo of age.

Question 6: When is Lucas considered infectious to others?

 Patients with measles are considered infectious from 3 days before to up to 4-6 days after the
rash.

Question 7: What are the common Complications that should be anticipated for this patient?
 Morbidity and mortality from measles are greatest in individuals younger than 5 yr ofage
(especially <1 yr of age)
  Severe malnutrition in children results in a suboptimal immune response and higher morbidity
and mortality with measles infection
 Infection in immunocompromised persons is associated with increased morbidity and
mortality
 Pneumonitis occurs in 58% and encephalitis occurs in 20%
 Pneumonia is the most common cause of death in measles
o May manifest as giant cell pneumonia caused directly by the viral infection or as
superimposed bacterial infection
 Following severe measles pneumonia, the final common pathway to a fatal outcome is often
the development of bronchiolitis obliterans
 Croup, tracheitis, and bronchiolitis are common complications in infants and toddlers with
measles
 Acute otitis media is the most common complication of measles.
 Sinusitis and mastoiditis also occur as complications.
 Viral and/or bacterial tracheitis is seen and can be life-threatening
 Retropharyngeal abscess
 Diarrhea and vomiting
o Dehydration is a common consequence, especially in young infants and children
 Appendicitis or abdominal pain may occur from obstruction of the appendiceal lumen by
lymphoid hyperplasia.
 Febrile seizures occur in <3% of children with measles
 Encephalitis is a postinfectious, immunologically mediated process and is not the result of a
direct effect by the virus
o Clinical onset begins during the exanthem and manifests as seizures (56%), lethargy
(46%), coma (28%), and irritability (26%)

Question 8: What are the preventive measures for this case?

Vaccine
○ Vaccination against measles is
the
most effective and safe
prevention
strategy
○ Measles vaccine is available as
a
combined vaccine with
measles-mumps-rubella vaccine
● Postexposure Prophylaxis
○ Susceptible individuals
exposed to
measles may be protected from
infection by either vaccine
administration or with Ig
○ The vaccine is effective in
prevention or modification of
measles if given within 72 hr of
exposure
○ Ig may be given up to 6 days
after
exposure to prevent or modify
infectio
Vaccine
○ Vaccination against measles is
the
most effective and safe
prevention
strategy
○ Measles vaccine is available as
a
combined vaccine with
measles-mumps-rubella vaccine
● Postexposure Prophylaxis
○ Susceptible individuals
exposed to
measles may be protected from
infection by either vaccine
administration or with Ig
○ The vaccine is effective in
prevention or modification of
measles if given within 72 hr of
exposure
○ Ig may be given up to 6 days
after
exposure to prevent or modify
infectio
Vaccine
○ Vaccination against measles is
the
most effective and safe
prevention
strategy
○ Measles vaccine is available as
a
combined vaccine with
measles-mumps-rubella vaccine
● Postexposure Prophylaxis
○ Susceptible individuals
exposed to
measles may be protected from
infection by either vaccine
administration or with Ig
○ The vaccine is effective in
prevention or modification of
measles if given within 72 hr of
exposure
○ Ig may be given up to 6 days
after
exposure to prevent or modify
infectio
Vaccine
○ Vaccination against measles is
the
most effective and safe
prevention
strategy
○ Measles vaccine is available as
a
combined vaccine with
measles-mumps-rubella vaccine
● Postexposure Prophylaxis
○ Susceptible individuals
exposed to
measles may be protected from
infection by either vaccine
administration or with Ig
○ The vaccine is effective in
prevention or modification of
measles if given within 72 hr of
exposure
○ Ig may be given up to 6 days
after
exposure to prevent or modify
infectio
Vaccine
○ Vaccination against measles is
the
most effective and safe
prevention
strategy
○ Measles vaccine is available as
a
combined vaccine with
measles-mumps-rubella vaccine
● Postexposure Prophylaxis
○ Susceptible individuals
exposed to
measles may be protected from
infection by either vaccine
administration or with Ig
○ The vaccine is effective in
prevention or modification of
measles if given within 72 hr of
exposure
○ Ig may be given up to 6 days
after
exposure to prevent or modify
infectio
 Avoidance of exposure of patients with measles who shed measles virus from 7 days after
exposure to 4-6 days after the onset of rash.
 Standard and airborne precautions in hospitals during infectious stage.
 Maintained isolation of immunocompromised patients with measles as measles virus is being
shed for the duration of the illness.

Vaccine:
o 1st dose: 12-15 months of age
o 2nd dose: 4-6 year of age
 2nd dose can be given any time after 30 days following the 1st dose.
 For children who have not received 2 doses by 11-12 yr of age, a 2nd dose should be
provided.
 Infants who receive a dose before 12 mo of age should be given 2 additional doses at 12-15
mo and 4-6 yr of age. Children who are traveling should be offered either primary measles
immunization even as young as 6 mo or a 2nd dose even if <4 yr.

Post-exposure prophylaxis:
 Susceptible individuals exposed to measles may be protected from infection by either vaccine
administration or with Ig.
 The vaccine is effective in prevention or modification of measles if given within 72 hr of
exposure. Ig may be given up to 6 days after exposure to prevent or modify infection.
 Immunocompetent children should receive 0.5 mL/ kg (maximum dose in both cases is 15
mL/kg) intramuscularly (IM).
 Ig intravenously is the recommended IG at 400 mg/kg. Ig is indicated for susceptible
household contacts of measles patients, especially infants younger than 6 mo of age, pregnant
women, and immunocompromised persons.