Just when it felt like it was safe to start looking forward to the spring and a reduced burden of infectious disease in our practices, the news arrived: measles has reared its head. First there were cases in the UK and now a small but concerning cohort has occurred in Ireland.
To make things more difficult, the symptom list for measles is similar to that with many other viral illnesses. The challenge of picking this needle from the pyrexial illness haystack is enough to make anyone want to be sent off for supportive management!
I was glad, therefore, to read through this recently updated GPnotebook section on the subject, which gives clarity on the presentation of this condition.
The updated section points out that patients are most likely to contact primary care with symptoms of measles, and we need to be alert from the first contact point with the surgery.
Patients contacting the practice with symptoms of fever and rash and at least one of coryza, conjunctivitis or cough should raise suspicion and prompt some further information gathering before arrival at the practice. Clarifying questions on a patient’s vaccine status, recent travel to an area where measles is circulating, and contact with a case of measles can help further with risk stratification.
The features of measles that could represent any viral illness include fever, malaise, coryza, conjunctivitis and cough. After this prodromal phase, some more helpful differentiating features occur. The rash of measles is erythematous and maculopapular, starting at the head and spreading to the trunk and limbs over 3–4 days. Some photos of the rash can be viewed here and are worth keeping on the computer for reference.
Koplik’s spots can be a helpful differentiating feature and occur in up to 70% of cases. Occurring around day 3–4, they often precede the rash and can be seen for 1–2 days after its onset. They appear as small red spots with blueish-white centres. They are located on the mucous membranes of the mouth.
In addition to making the diagnosis, we should remember that these patients are at risk of complications of measles.
The page linked to immediately above reminds us to assess for signs of otitis media (occurring in 7–9% of cases) and bronchopneumonia (1–6%, often as a Staphylococcus aureus or gram-negative bacterial pneumonia). Other common features are diarrhoea and febrile convulsions. Meningitis and encephalitis are thankfully less common but do occur with measles, and we should assess and document if features of either are present.
Our pregnant patients and immunocompromised patients are particularly at risk if they get measles; they need careful attention as they carry higher complication and mortality rates.
When seeing patients with suspected measles, we should protect ourselves, other staff members and other patients attending the practice. Following local infection control guidelines may involve seeing the patient towards the end of the day, avoiding contact with other patients, wearing appropriate PPE and not using the room for a period of time after the consultation.
Confirmation of the diagnosis is essential and can be done with a buccal or salivary swab. On writing this column, there was also a recommendation from the Health Protection Surveillance Centre for same-day reporting of suspected cases of this highly infectious condition by telephone to a medical officer of health.
Management of a confirmed case of measles is often supportive, involving isolation, analgesics, safety netting and treatment of bacterial superinfection. Management of contacts should be in partnership with public health recommendations and specialist colleagues, and it can involve a post-exposure MMR vaccine. Some groups cannot take the MMR vaccine (e.g. pregnant women) and may require intravenous immunoglobulin.
An audit of eligible patients who have not received the MMR vaccine could also be timely and improve the overall protection of the practice population from this infectious condition. The HSE website provides up-to-date information on vaccine recommendations for healthcare professionals and patients.
I hope you found this update useful and timely. I look forward to writing for you again next month.