morbilliii

8/19/2019 morbilliii

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Preceptor:

dr. Ulynar Marpaung, Sp.A

Presenter:Fitria Nurulfath

(1102010105)

Pediatric DepartmentRaden Said Soekanto Hospital

Yarsi Medical UniversityPeriode u!ust "rd # $cto%er &&th '(&)

Case Presentation

Morbilli


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Patient Identity

• Nae ! ".A

• #irt$ %ate ! May &t$ 2005

• Age ! 10 years ' ont$s

• ender ! Male

• Address ! P *ANSI '+ CIA-AN. ast /aarta

• Nationality ! Indonesia

• -eligion ! Mosle

• %ate o adission ! August 25t$ 2015

• %ate o eaination ! August 25t$ 2015


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Parent Identity

Father Mother

Nae Mr. S Mrs. M

Age &0 years old '3 years old

/o4 ployee ouse6ie

Nationality Indonesia Indonesia

-eligion Isla Isla

du7ation ig$ S7$ool ig$ S7$ool


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istory *aing

•The anamnesis was taken on August 25th 2 015, using alloanamnesis method.

•

•Fever since four days prior to admission at hospital.

•ash, cough, flu, headache, nausea, vomiting, diarrhea, a!dominal pain

C$ie 7oplain !

Additional 7oplains !


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istory o Present

IllnessA 10 years old 4oy 7ae to -aden

Said Suanto Poli7e Center ospital

su8ering ro fever since four days4eore adission to t$e $ospital. *$is7oplains also ollo6ed 4y rash allover his %ody* cough, flu, headache,nausea, vomiting, diarrhea, abdominal pain

since 4 days and swallowing pain since 1 day

!efore admission.


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istory o Present Illness(2)

For the !lood test results in emergency room"25th August 2015# are Hb 12.8 g/dl, leukocytes

4.9 u/l, hematocrit !"#, trom!ocytes2$%.000&ul, and erythrocyte %.'( )t&ul

*n the days of hospital admission, patientcondition was compos mentis. $ash, fever,cough, flu, headache, diarrhea still e+ist.


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istory o Present

Illness

% days !eforeadmission the patient

had cough, flu,headache, nausea,vomiting, a!dominal pain, diarrhea times aday

Sin7e & days4eoreadission t$epatient $ade9er, ras$ all

o9er $is 4ody

1 day 4eoreadission t$epatient $ads6allo6ing pain


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istory o Past IllnessPharyn!itis +

,onsilitis- .acillary

Dysentry/

#ron7$itis : Aoe4a%ysentry

:

Pneuonia : %iarr$ea ;

Mor4illi : *$ypoid :

Pertussis : ra7ture :

Polio : %rug -ea7tion :

nteritis :


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Prenatal istory

• Antenatal Care

Antenatal 7$e7 ups perored at t$e lo7al7lini7 4y a do7tor sin7e s$e ne6 s$e?spregnant and e9ery ont$s until s$e ga9e4irt$. *$ere 6as no pro4les duringpregnan7y.

• No aternal illness during pregnan7y


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#irt$ istory

• "a4or ! Clini7

• #irt$ attendants ! %o7tor

• Mode o deli9ery ! Per9agina

• estation ! '@ 6ees

• Inant state ! ealt$y

• #irt$ 6eig$t ! '&00 gras

• #ody lengt$ ! 50 7

• A77ording to t$e ot$er, t$e 4a4y started to 7ry and t$e4a4ys sin is red, no 7ongenital dee7ts 6ere reported


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%e9elopent istory

• >irst dentition! ont$s old

• Psy7$ootor de9elopent• Sile ! 1 ont$ old

• Slant ! 2 ont$s old

• Spee7$ Initation ! 2 ont$s old

• Prone Position ! & ont$s old

• Sitting ! ont$s old

• Cra6ling ! @ ont$s old

• Standing ! 10 ont$s old

•


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History of 0atin!

• #reast il! ont$s

• >orula il! SM sin7e t ont$s old

• #a4y 4is7uit! #is7uit Milna and -egal

• >ruit and 9egeta4les! #anana, papaya

1mmuni2ationHistory

IuniBation >reuen

7y

*ie

epatitis # ' ties 0,1,

ont$s old

Polio & ties 0,2,&,ont$s old

#C 1 tie 1 ont$

old

%P* ' ties 2,&,

ont$s oldi4 ' ties 2,&,

ont$s old

Measles 1 tie D ont$s

old


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>aily istory

• *$ere are not any signiE7ant illnesses or7$roni7 illnesses 4ased on t$e parent

de7lared.


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istory o %isease in Gt$er >aily Me4ers + Around t$e

ouse

• er neig$4or?s son $ad easles a 6eeago.


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P$ysi7al aination

Date : u!ust ')th '(&)

3eneral Status

• eneral 7ondition! Mildly ill

• Cons7iousness ! Copos Mentis

• Pulse ! 100 +in, regular, ull, strong.

• #reat$ing rate ! 20 +in

• *eperature ! '@.'oC (per ailla)

nthropometry Status

•


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ntropometryStatus


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Head ,oe 07amination

• HeadNoro7ep$aly, $air (4la7, noraldistri4ution, not easily reo9ed) sign otraua (:), ras$ (;)

• 0yesI7teri7 s7lera :+:, 7onJun7ti9itis ;+;,la7riation :+:, s6ollen eyes :+:, pupils'+' isoor, dire7t and indire7t lig$t

response ;;+;;.• 0arsNoral s$ape, no 6ound, no 4leeding,se7retion or seruen :+:, ras$ (;)

• NoseNoral s$ape, idline septu, se7retion :+:,


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Mouth

• "ips ! %ry

• Mu7ous ! Moist

• *ongue ! Not dirty

• *onsils ! *1+*1, no $ypereia

• P$aryn ! ypereia

Neck

• "yp$ node enlargeent (;), s7roulodera (:), ras$ (;)

Head ,oe 07amination 5'6


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,hora7

• Inspe7tion ! syetri7 6$en 4reat$ing, retra7tion

(:), i7tus 7ordis is not 9isi4le.

• Palpation ! ass (:), ta7tile reitus ;+;

• Per7ussion ! sonor on 4ot$ lungs

• Aus7ultation

Cor ! regular S1:S2, urur (:), gallop (:)Pulo ! 9esi7ular ;+;, 6$eeBing :+:, r$on7$i :+:

-as$ (;)

Head ,oe 07amination 5"6


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%domen

• Inspe7tion ! Con9e, epigastri7 retra7tion (:),

t$ere is no 6idening o t$e 9eins, no spider ne9i.

• Palpation ! supple, li9er and spleen not

palpa4le, Kuid 6a9e (:), a4doinal ass (:)

•

Per7ussion! *$e entire Eeld o typani7a4doen, s$iting dullness (:)

• Aus7ultation! noral 4o6el sound, 4ruit (:)

• -as$ ;

Head ,oe 07amination 586


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•9erte%ra

*$ere does not appear s7oliosis, yp$osis, and

lordosis, do not loo any ass along t$e line ot$e 9erte4ral

•07tremities


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Neurolo!ical07amination

Meningeal sign

Nu7$al rigidity :

ernig sign :

"asegue sign :

#rudBinsi 1 :

#rudinsi 2 :


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Motori7 aination

Po6er

and

>eet

5 5 5 5+ 5 5 5 5

5 5 5 5+ 5 5 5 5

*onus

and

>eet

Norotonus + Norotonus

Norotonus + Norotonus

*rop$y

and

>eet

Norotrop$y + Norotrop$y

Norotrop$y + Norotrop$y


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P$ysiologi7 -eKe

Upper etriities

#i7eps

*ri7eps

"o6er etriities

Patella

A7$illes

; + ;

; + ;

; + ;

; + ;

Motoric 07amination 5'6


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Pat$ologi7 -eKe

Upper etriities

o8an

*roer

"o6er etriities

#a4insy

C$addo7

Gppen$ei

ordon

S7$ae8er

: + :

: + :

: + :

: + :

: + :

: + :

: + :

Motori7 aination (')

Clonus

Patella

A7$illes

: + :

: + :

t


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%ee7ation

Urination S6eating

Noral ( 1:2 ties daily)

Noral ( &:5 ties daily ) Noral

utonom07amination


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%aboratory &nvestigation

Hematol!y Result Normal 9alue

aeoglo4in 12.8 g/d% 1!'1( g/d%

"euo7ytes 4.9/u% 5,000 - 10,000&/

eato7rits !" # %0 - %(

*ro4o7ytes 2$%.000& u/ 150,000 - %00,000&/

ryt$ro7ytes%.'( million&u/ % - 5 million&/


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Manageent

• F3 / 1'50cc 22dpm

• n). 4efota+ime 2 + 1 g i.v.

• Am!ro+ol + 1 c

• anmol + 1 c

• /acto 6 2 + 1 sach

• 7inkid 1 + 1 c

• 3omperidone 2 + 1 c

• it A 1+200.000 units


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• uo ad 9ita ! du4ia ad 4ona

•

uo ad un7tiona ! du4ia ad 4ona• uo ad sana7tiona ! du4ia ad

4ona

Pro!nosis


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>ollo6 Up ( August 2t$ 2015 )) *ough +-

$ash +-*orya +-Fever "8#

* 9eneral condition: 4ompos ;entis


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>ollo6 Up (August 23t$ 2015 )

• S ! C$est pain 6$en 4reat$ing still persist 4ut t$e pain is redu7ed,s$ortness o 4reat$ (:), su4e4rile e9er (:), diBBiness (:) and 7oug$ isredu7ed.

• G ! Copos Mentis

• Pulse ! @@ +in, regular, ull, strong.

• #reat$ing rate ! ''7+min

• *eperature ! 'oC (per ailla)

• Pulo ! inter7ostal retra7tion (:), 9esi7uler ;+;, 6$eeBing :+:, rhoncy -+-

• Cor! S1+S2 reguler, no urur, no gallop

• A ! Suspe7t lung *# dd+ 4ron7$opneuoni

• P ! Patient 7an go $oe.

Patient is ased to 7$e7 Mantou test, t$en 4ring t$e result to t$epoly7lini7.

) *ough +-$ash +-*orya +-Fever "@#



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>ollo6 Up (August 2@t$ 2015 )

• S ! C$est pain 6$en 4reat$ing still persist 4ut t$e pain is redu7ed,s$ortness o 4reat$ (:), su4e4rile e9er (:), diBBiness (:) and 7oug$ isredu7ed.

• G ! Copos Mentis

• Pulse ! @@ +in, regular, ull, strong.

• #reat$ing rate ! ''7+min

• *eperature ! 'oC (per ailla)

• Pulo ! inter7ostal retra7tion (:), 9esi7uler ;+;, 6$eeBing :+:, rhoncy -+-

• Cor! S1+S2 reguler, no urur, no gallop

• A ! Suspe7t lung *# dd+ 4ron7$opneuoni

• P ! Patient 7an go $oe.

Patient is ased to 7$e7 Mantou test, t$en 4ring t$e result to t$epoly7lini7.

) *ough +-$ash +-Fever "@#



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"iterature -e9ie6


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%eEnition

• Measles is an a7ute 7$ild$ood ine7tious disease7aused 4y a 9irus. *$e 9irus is transitted roperson to person t$roug$ 7oug$ing or sneeBing.

*$e disease is 7$ara7teriBed 4y!

a generaliBed, reddis$ (eryt$eatous),4lot7$y (a7ulopapular) ras$O

a $istory o e9er usually a4o9e '@>C (i not

easured, t$en $ot to tou7$)O and at least one o t$e ollo6ing : 7oug$, runny

nose (7oryBa), or red eyes (7onJun7ti9itis).


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tiology

• Measles 9irus is a single:stranded, lipid:en9eloped-NA 9irus in t$e aily Parayo9iridae andgenus Mor4illi9irus.

• G t$e aJor stru7tural proteins o easles 9irus,t$e 2 ost iportant in ters o indu7tion oiunity are t$e $eagglutinin () protein andt$e usion (>) protein.

• *$e neutraliBing anti4odies are dire7ted againstt$e protein, and anti4odies to t$e > protein liitprolieration o t$e 9irus during ine7tion.


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Pat$ogenesis andPat$ology

•

*$e portal o entry o easles 9irus is t$roug$ t$e respiratorytra7t or 7onJun7ti9ae ollo6ing 7onta7t 6it$ large droplets orsall:droplet aerosols in 6$i7$ t$e 9irus is suspended.

• Patients are ine7tious ro ' days 4eore to up to &: days atert$e onset o ras$. Approiately D0H o eposed sus7epti4le

indi9iduals eperien7e easles.

• >a7e:to:a7e 7onta7t is not ne7essary, 4e7ause 9ia4le 9irus ay4e suspended in air or as long as 1 $our ater t$e patient 6it$t$e sour7e 7ase lea9es a roo. Se7ondary 7ases due to spread o

aerosoliBed 9irus $a9e 4een reported in p$ysi7ians? oQ7es and in$ospitals.

• Measles ine7tion 7auses ne7rosis o t$e respiratory tra7tepit$eliu and an a77opanying lyp$o7yti7 inEltrate.

• Measles produ7es a sall 9essel 9as7ulitis on t$e sin and on t$e


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Measles consists of " phases:

• In7u4ation period (@:12days)! It 4egins 6it$ a ild e9erollo6ed 4y t$e onset o 7onJun7ti9itis 6it$ p$otop$o4ia,7oryBa, a proinent 7oug$, and in7reasing e9er. %uringin7u4ation, easles 9irus igrates to regional lyp$ nodes. A

priary 9ireia ensues t$at disseinates t$e 9irus to t$ereti7uloendot$elial syste. A se7ondary 9ireia spreads 9irusto 4ody sura7es and is asso7iated 6it$ epit$elial ne7rosis andgiant 7ell oration in 4ody tissues.

• opli spots represent t$e enant$e and are t$e

pat$ognooni7 sign o easles, appearing 1 to & days prior tot$e onset o t$e ras$. *$ey Erst appear as dis7rete red lesions6it$ 4luis$ 6$ite spots in t$e 7enter on t$e inner aspe7ts ot$e 7$ees at t$e le9el o t$e preolars.


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• ant$eatous+eruption p$ase! *$e ras$ 4egins ont$e ore$ead (around t$e $airline), 4e$ind t$e ears,and on t$e upper ne7 as a red a7ulopapulareruption. It t$en spreads do6n6ard to t$e torso

and etreities, rea7$ing t$e pals and soles inup to 50H o 7ases. *$e eant$e reuently4e7oes 7onKuent on t$e a7e and upper trun

• -e7o9ery p$ase !


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Signs and syptos

• $ig$ e9er

• enant$e 7oug$

• 7oryBa

• 7onJun7ti9itis

• a proinent eant$ea.

• opli spots

• diarr$ea


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%iagnosis

• *$e diagnosis o easles is alost al6ays 4ased on7lini7al and epideiologi7 Endings. "a4oratory Endingsin t$e a7ute p$ase in7lude redu7tion in t$e total 6$ite

4lood 7ell 7ount, 6it$ lyp$o7ytes de7reased oret$an neutrop$ils. A4solute neutropenia $as 4eenno6n to o77ur, $o6e9er.

• Serologi7 7onEration is ost 7on9eniently ade 4yidentiE7ation o iunoglo4ulin M (IgM) anti4ody in

seru. Serologi7 7onEration ay also 4e ade 4ydeonstration o a ourold rise in Ig anti4odies ina7ute and 7on9ales7ent spe7iens 7olle7ted 2:&6ees later.

S ti


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Supportingaination

• C$est radiograp$y

• I 4a7terial pneuonia is suspe7ted, peror 7$estradiograp$y. *$e reuent o77urren7e o easles

pneuonia, e9en in un7opli7ated 7ases, liits t$epredi7ti9e 9alue o 7$est radiograp$y or 4a7terial4ron7$opneuonia.

• "u4ar pun7ture

• I en7ep$alitis is suspe7ted, peror a lu4ar pun7ture.

CS> eaination re9eals t$e ollo6ing!• In7reased protein

• Noral glu7ose

• Mild pleo7ytosis 6it$ a predoinan7e o lyp$o7ytes


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Manageent• Manageent o easles is supporti9e. Maintenan7e o $ydration,

oygenation, and 7oort are goals o t$erapy. Antipyreti7s or7oort and e9er 7ontrol are useul.

• Anti9iral t$erapy is not e8e7ti9e in t$e treatent o easles inot$er6ise noral patients.

• >or patients 6it$ respiratory tra7t in9ol9eent, air6ay $uidi:E7ation and suppleental oygen ay 4e o 4eneEt. -espiratoryailure due to 7roup or pneuonia ay reuire 9entilatory support.

• Gral re$ydration is e8e7ti9e in ost 7ases, 4ut se9ere de$ydrationay reuire intra9enous t$erapy.

• =itain A deE7ien7y in 7$ildren in de9eloping 7ountries $as long4een no6n to 4e asso7iated 6it$ in7reased ortality ro a 9arietyo ine7tious diseases, in7luding easles. *$e Aeri7an A7adey oPediatri7s suggests 9itain A t$erapy or sele7ted patients 6it$easles


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Pre9ention

• 0he measles virus vaccine is routinely administered along with the

mumps and rubella vaccines as the measles'mumps'rubella +$-

vaccine.

• The current recommendations include a first dose at B months old followed !y

a second dose at 2% moths old and ' years old for measles and first dose at 15months old and followed !y second dose at 5@' years old.

• *ontraindications to the vaccine include

• immunodeficiency

• generalied cancers +eg, leuemia, lymphoma-

• active, untreated tuberculosis

• therapy with immunosuppressants.

• H&3 infection is only a contraindication in the presence of severe

immunosuppression +ie, *4 counts lower than 1"#-.


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Copli7ation

• Mor4idity and ortality ro easles aregreatest in patients 5 years o age(espe7ially 1 years o age) and 20 years o age

• Se9ere alnutrition in 7$ildren results insu4optial iune response and $ig$eror4idity and ortality 6it$ easlesine7tion.


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• Pneuonia is t$e ost 7oon 7ause o deat$ ineasles. It ay aniest as giant 7ell pneuonia7aused dire7tly 4y t$e 9iral ine7tion or assuperiposed 4a7terial ine7tion. *$e ost

7oon 4a7terial pat$ogens are Strepto7o77uspneuoniae, aeop$ilus inKuenBae, andStap$ylo7o77us aureus


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• Su4a7ute s7lerosing panen7ep$alitis (SSP) is a7$roni7 7opli7ation o easles 6it$ a delayed onsetand an out7oe t$at is nearly al6ays atal.

• It appears to result ro a persistent ine7tion 6it$an altered easles 9irus t$at is $ar4oredintra7ellularly in t$e CNS or se9eral years.

• Ater 3:10 years t$e 9irus apparently regains

9irulen7e and atta7s t$e 7ells in t$e CNS t$ato8ered t$e 9irus prote7tion. *$is Rslo6 9irusine7tion results in inKaation and 7ell deat$,leading to an ineora4le neurodegenerati9e pro7ess.


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