eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Measles: Differential Diagnoses & Workup

Author: Selina SP Chen, MD, MPH, Assistant Professor of Pediatrics, Department of Internal Medicine, John A Burns School of Medicine, University of Hawaii; Internal Medicine and Pediatric Hospitalist, Kapiolani Medical Center for Women and Children; Internal Medicine Hospitalist, Straub Clinic and Hospital
Coauthor(s): Glenn J Fennelly, MD, MPH, Director, Division of Pediatric Infectious Diseases, Jacobi Medical Center; Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Jun 10, 2009

Differential Diagnoses

Dengue
Parvovirus B19 Infection
Drug Eruptions
Pediatrics, Roseola Infantum
Enteroviral Infections
Pediatrics, Scarlet Fever
Infectious Mononucleosis
Rocky Mountain Spotted Fever
Kawasaki Disease
Rubella
Meningococcemia
Toxic Shock Syndrome

Workup

Laboratory Studies

Diagnosis of measles is usually determined from the classic clinical picture.

  • Confirmation of measles virus (MV) infection
    • The measles virus sandwich-capture immunoglobulin M (IgM) antibody assay is the quickest method to confirm acute measles. Because IgM may not be detectable during the first 2 days of rash, obtain blood for measles-specific IgM on the third day of the rash or on any subsequent day up to one month after onset to avoid a false-negative IgM result. Among persons with confirmed measles infection, the seropositivity rate for first samples is about 77% when collected within 72 hours; the rate rises to 100% when collected 4-11 days after rash onset.7 Although the measles serum IgM level remains positive 30-60 days after the illness in most individuals, the IgM titer may become undetectable in some subjects at 4 weeks after rash onset. The assay is offered through many local health departments and through the Centers for Disease Control and Prevention (CDC).
    • Laboratories can confirm measles by demonstrating more than a 4-fold rise in immunoglobulin G (IgG) antibodies between acute and convalescent sera. IgG antibodies may be detectable 4 days after the onset of the rash, although most cases have detectable IgG antibodies by about a week after rash onset. Thus, take specimens on the seventh day after rash onset and repeat 10-14 days later to confirm the case as soon as possible. Patients with subacute sclerosing panencephalitis (SSPE) have unusually high titers of measles antibody in their serum and cerebrospinal fluid. The earliest confirmation of measles using IgG antibodies takes about 3 weeks from the onset of illness, a delay too long to permit implementation of effective control measures.
    • Measles virus can be isolated from nasopharyngeal swabs. Viral genotyping in a reference laboratory may determine whether an isolate is endemic or imported. In immunocompromised patients, who may have poor antibody responses that preclude serologic confirmation of measles, virus isolation from infected tissue or identification of measles antigen by immunofluorescence may be the only method to confirm the diagnosis.
  • Other diagnostic tests
    • A leukopenia with a relative lymphocytosis occurs in the late stages of viremia.
    • Elevated hepatic transaminase levels may be detected in patients with measles virus hepatitis.

Imaging Studies

  • Perform chest radiography if bacterial pneumonia is suspected. The frequent occurrence of measles pneumonia, even in uncomplicated cases, limits the predictive value of chest radiography for bacterial bronchopneumonia.

Other Tests

  • Perform a lumbar puncture if encephalitis is suspected. 
  • Cerebrospinal fluid examination reveals the following:
    • Increased protein
    • Normal glucose
    • Mild pleocytosis with a predominance of lymphocytes

Histologic Findings

  • Lymphoid multinucleated giant cells (£ 100 nm in diameter) can be identified in biopsies of Koplik spots, in dermal or epithelial rashes, and in lung or lymphoid tissue.
  • Brain biopsies of patients with measles encephalitis can reveal demyelination, vascular cuffing, gliosis, and infiltration of fat-laden macrophages near blood vessel walls.

More on Measles

Overview: Measles
Differential Diagnoses & Workup: Measles
Treatment & Medication: Measles
Follow-up: Measles
Multimedia: Measles
References
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References

  1. [Guideline] Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0 through 18 years---United States, 2009. CDC Recommended Vaccine Schedule. Dec 2008;57(51;52):[Full Text].

  2. Meissner HC, Strebel PM, Orenstein WA. Measles vaccines and the potential for worldwide eradication of measles. Pediatrics. 2004;114(4):1065-9. [Medline]. [Full Text].

  3. Smeeth L, Cook C, Fombonne E, et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet. 2004;11-17;364(9438):963-9. [Medline].

  4. Centers for Disease Control and Prevention. Program in brief: Measles Mortality Reduction and Regional Global Measles Elimination. Available at http://www.cdc.gov/ncird/progbriefs/downloads/global-measles-elim.pdf. Accessed April 14, 2009.

  5. Forni AL, Schluger NW, Roberts RB. Severe measles pneumonitis in adults: evaluation of clinical characteristics and therapy with intravenous. Clin Infect Dis Sep. 1994;19(3):454-62. [Medline].

  6. Garenne M. Sex differences in measles mortality: a world review. Int J Epidemiol. Jun 1994;23(3):632-42. [Medline].

  7. Helfand RF, Heath JL, Anderson LJ, et al. Diagnosis of measles with an IgM capture EIA: the optimal timing of specimen collection after rash onset. J Infect Dis. Jan 1997;175(1):195-9. [Medline].

  8. American Academy of Pediatrics. Measles. In: Pickering LK, ed. Red Book: Report of the Committee on Infectious Disease. Elk Grove, Ill: AAP; 2006:441-52.

  9. Hosoya M, Shigeta S, Mori S, et al. High-dose intravenous ribavirin therapy for subacute sclerosing panencephalitis. Antimicrob Agents Chemother. Mar 2001;45(3):943-5. [Medline].

  10. Centers for Disease Control and Prevention. CDC Guide to Vaccine Contraindicatons and Precautions. Available at http://www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf. Accessed April 14, 2009.

  11. Centers for Disease Control and Prevention. Global measles control and regional elimination, 1998-1999. MMWR Morb Mortal Wkly Rep. Dec 17 1999;48(49):1124-30. [Medline].

  12. Centers for Disease Control and Prevention. Measles--United States, 1999. MMWR Morb Mortal Wkly Rep. Jun 30 2000;49(25):557-60. [Medline].

  13. Centers for Disease Control and Prevention. Progress toward global measles control and elimination, 1990-1996. MMWR Morb Mortal Wkly Rep. Sep 26 1997;46(38):893-7. [Medline].

  14. Centers for Disease Control and Prevention. Strategies for reducing global measles mortality. Wkly Epidemiol Rec. Dec 15 2000;75(50):411-6. [Medline].

  15. Gershon AA. Measles virus (rubeola). In: Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. Philadelphia, Pa: Churchill Livingstone; 1995:1519-26.

  16. Griffin DE, Bellini WJ. Measles virus. In: Fields BN, Knipe DM, Howley PM, eds. Fields Virology. 3rd ed. Philadelphia, Pa: Lippincott; 1996.

  17. Griffin, DE. Billeter M, ed. Measles Virus. New York, NY: Springer-Verlag; 1995:117-34.

  18. Perry RT, Mmiro F, Ndugwa C, Semba RD. Measles infection in HIV-infected African infants. Ann N Y Acad Sci. Nov 2000;918:377-80. [Medline].

  19. Shah BR, Laude TA. Measles. In: Atlas of Pediatric Clincal Diagnosis. WB Saunders Co; 2000:59-61.

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Further Reading

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Keywords

measles, rubeola, Koplik spots, measles virus, MV, rubeola virus, coryza, conjunctivitis, pathognomonic enanthem, Koplik spots, otitis media, bronchopneumonia, acute encephalitis, subacute sclerosing panencephalitis, SSPE, autism, giant cell pneumonia, interstitial pneumonitis, laryngotracheobronchitis, croup, tuberculosis, encephalomyelitis, hemorrhagic measles, purpura fulminans, hepatitis, disseminated intravascular coagulation, DIC, transient hepatitis, generalized lymphadenopathy, mild hepatomegaly, appendicitis, treatment, diagnosis

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Contributor Information and Disclosures

Author

Selina SP Chen, MD, MPH, Assistant Professor of Pediatrics, Department of Internal Medicine, John A Burns School of Medicine, University of Hawaii; Internal Medicine and Pediatric Hospitalist, Kapiolani Medical Center for Women and Children; Internal Medicine Hospitalist, Straub Clinic and Hospital
Selina SP Chen, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Physicians-American Society of Internal Medicine, and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Glenn J Fennelly, MD, MPH, Director, Division of Pediatric Infectious Diseases, Jacobi Medical Center; Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine
Glenn J Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital
Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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