Morbilli Tegar Wibawa Rachman1102009281

Preceptor : dr. Ulynar Marpaung, Sp.A.

Faculty of MedicineYARSI UNIVERSITY Department of PediatricBhayangkara tk.I R.S. Sukanto Hospital - JakartaPeriod : 25th May 1st July of 2015

Patient IdentityName : Child IBirth Date: February 22nd , 2012 Age: 3 years 3 monthsGender: FemaleAddress: Cilitan Kecil RT 001/007 Kramat Jati, East JakartaNationality: IndonesiaReligion: MoslemDate of admission: June 3rd 2015Date of examination: June 4th 2015

Parent Identity

FatherMotherNameMr. SMrs. RAge37 years old35 years oldJobMerchantHousewifeNationalityJavaneseJavaneseReligionIslamIslamEducationUndergraduateHigh School

History TakingThe anamnesis was taken on June 4th 2015 until, using alloanamnesis method.The anamnesis taken at room no.6 Anggrek I Ward, RS POLRI R Said Sukanto

Fever since three days prior to admission at hospital.

Rash, itch , cough , flu, diarrhea, decrease in body weight Chief complain :Additional complains :

History of Present Illness

History of Past Illness

Pharyngitis / Tonsilitis+Bacillary Dysentry-Bronchitis-Amoeba Dysentry-Pneumonia-Diarrhea+Morbilli-Thypoid-Pertussis-Worms-Varicella-Surgery-Diphteria-Brain Concussion-Malaria-Fracture-Polio-Drug Reaction-Enteritis-

Prenatal HistoryAntenatal Care Antenatal check ups performed at the local clinic by a doctor since she knew shes pregnant and every months until she gave birth. There was no problems during pregnancy.

No maternal illness during pregnancy

Drugs consumption: Vitamins, iron supplement and folic acid every antenatal care

Birth HistoryLabor : ClinicBirth attendants: DoctorMode of delivery: PervaginamGestation: 38 weeksInfant state: healthyBirth weight : 2900 gramsBody length: 50 cmAccording to the mother, the baby started to cry and the baby's skin is red, no congenital defects were reported

Development HistoryFirst dentition: 6 months oldPsychomotor development Smile: 1 month oldSlant: 2 months oldSpeech Initation: 2 months oldProne Position: 4 months oldSitting: 6 months oldCrawling: 8 months oldStanding: 10 months oldWalking: 12 months oldConclusion: growth and developmental is still in the normal limits and was appropriate according to the patients age

Immunization History

ImmunizationFrequencyTimePolio3 times0,1,3 months oldHepatitis B 2 times 0,1 month oldDPT3 times2,4,6 months oldBCG1 time1 month old

Family HistoryThere are not any significant illnesses or chronic illnesses based on the parent declared.

History of Disease in Other Family Members / Around the HouseHer neighbors son had measles a week ago.

Physical ExaminationDate : June 4th 2015General StatusGeneral condition: Mildly illConsciousness: Compos MentisPulse: 100x /min, regular, full, strong.Breathing rate: 32x /minTemperature: 36.5oC (per axilla)

Anthropometry Status Weight: 11 kilogramHeight: 89 cm

WFA (Weight for Age): 11/14 x 100 % = 78.5 % (undernourished)HFA (Height for Age): 89/94 x 100 % = 94.6 % (good nutrition)WFH (Weight for Height): 11/14 x 100 % = 78.5 % (undernourished)

Conclusion: The patient has undernourished nutritional status.

Systemic Physical Examination

Head and NeckNormocephaly, hair (black, normal distributon, not easily removed ) sign of trauma (-), large fontanelle closed. Lymph node enlargement (-), scrofuloderma (-)Rash (+)MouthLips dry, mucous moist, coated tongue (-), pharynx hyperemia (+), tonsil T1/T1Pulmo Symmetric when breathing , intercostal retraction (-), vesicular +/+, wheezing -/-, rhonchy -/- Rash (+)CorS1S2 regular, murmur (-), gallop (-)AbdomenNo distention, epigastric retraction (-), Bowel sound (+) normal, hepatosplenomegaly (-), good turgor Rash (+)ExtremitiesWarm, capillary refill time < 2s, edema (-) Rash (+)

Laboratory ResultHematology ( June 4th 2015 )

HematolgyResultNormal ValueHaemoglobin11.7 g/dL12-14 g/dLLeukocytes8.100/L5,000 10,000/LHematocrits36 %40 48 %Trombocytes241.000/ L150,000 400,000/L Erythrocytes4.51 million/L4 5 million/L

Working DiagnosisMorbilli DD/ Dengue Fever

ManagementIVFD RL loading, macro drip, 14 dpm 1000cc / 24 Hours.Inj. Cefotaxime 2x500 mg IVParacetamol 4x120mgAmbroxol syrup 3x1 cthVit A 1x200.000 units

Follow Up ( June 4th 2015 )

SCough (+)Rash (+)Coryza (+)Fever (-)OGeneral condition: Compos MentisHeart rate = 100x /minRespiratory rate = 26x /minTemperature = 36.5CCardio : S1/S2, reguler, no murmur, no gallopPulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-Abdomen : distention (-), bowel sound (+) normalRash (+)AMorbilliP IVFD RL, macro drip, 14 dpm 1000cc / 24 Hours.Inj. Cefotaxime 2x 500 mg IVParacetamol 4x120mg POAmbroxol 3x1cthVit. A 1x 200.000 units

Follow Up (June 5th 2015 )S : Chest pain when breathing still persist but the pain is reduced, shortness of breath (-), subfebrile fever (-), dizziness (-) and cough is reduced.

O : Compos MentisPulse: 88 x/min, regular, full, strong.Breathing rate: 22x/minTemperature: 36oC (per axilla)Pulmo: intercostal retraction (-), vesiculer +/+, wheezing -/-, rhoncy +/+Cor: S1/S2 reguler, no murmur, no gallop

A : Suspect lung TB dd/ bronchopneumoni

P : Patient can go home. Patient is asked to check Mantoux test, then bring the result to the polyclinic.

SCough (+)Rash (+)Coryza (+)Fever (-)OGeneral condition: Compos MentisHeart rate = 110x /minRespiratory rate = 24x /minTemperature = 36CCardio : S1/S2, reguler, no murmur, no gallopPulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-Abdomen : distention (-), bowel sound (+) normalRash (+)AMorbilliP IVFD RL, macro drip, 14 dpm 1000cc / 24 Hours.Inj. Cefotaxime 2x 500 mg IVParacetamol 4x120mg POAmbroxol 3x1cthVit. A 1x 200.000 units

PrognosisQuo ad vitam: dubia ad bonam Quo ad functionam: dubia ad bonamQuo ad sanactionam: dubia ad bonam

Literature Review

EtiologyMeasles virus is a single-stranded, lipid-enveloped RNA virus in the family Paramyxoviridae and genus Morbillivirus. Of the 6 major structural proteins of measles virus, the 2 most important in terms of induction of immunity are the hemagglutinin (H) protein and the fusion (F) protein.The neutralizing antibodies are directed against the H protein, and antibodies to the F protein limit proliferation of the virus during infection.

Pathogenesis and PathologyThe portal of entry of measles virus is through the respiratory tract or conjunctivae following contact with large droplets or small-droplet aerosols in which the virus is suspended.Patients are infectious from 3 days before to up to 4-6 days after the onset of rash. Approximately 90% of exposed susceptible individuals experience measles. Face-to-face contact is not necessary, because viable virus may be suspended in air for as long as 1 hour after the patient with the source case leaves a room. Secondary cases due to spread of aerosolized virus have been reported in physicians offices and in hospitals.Measles infection causes necrosis of the respiratory tract epithelium and an accompanying lymphocytic infiltrate. Measles produces a small vessel vasculitis on the skin and on the oral mucous membranes

Measles consists of 3 phases:Incubation period (8-12days): It begins with a mild fever followed by the onset of conjunctivitis with photophobia, coryza, a prominent cough, and increasing fever. During incubation, measles virus migrates to regional lymph nodes. A primary viremia ensues that disseminates the virus to the reticuloendothelial system. A secondary viremia spreads virus to body surfaces and is associated with epithelial necrosis and giant cell formation in body tissues.Koplik spots represent the enanthem and are the pathognomonic sign of measles, appearing 1 to 4 days prior to the onset of the rash. They first appear as discrete red lesions with bluish white spots in the center on the inner aspects of the cheeks at the level of the premolars.

Exanthematous/eruption phase: The rash begins on the forehead (around the hairline), behind the ears, and on the upper neck as a red maculopapular eruption. It then spreads downward to the torso and extremities, reaching the palms and soles in up to 50% of cases. The exanthem frequently becomes confluent on the face and upper trunk Recovery phase :With the onset of the rash, symptoms begin to subside. The rash fades over about 7 days in the same progression as it evolved, often leaving a fine desquamation of skin in its wake

Signs and symptomshigh feverenanthem coughcoryzaconjunctivitisa prominent exanthema. Koplik spots diarrhea

DiagnosisThe diagnosis of measles is almost always based on clinical and epidemiologic findings. Laboratory findings in the acute phase include reduction in the total white blood cell count, with lymphocytes decreased more than neutrophils. Absolute neutropenia has been known to occur, however. Serologic confirmation is most conveniently made by identification of immunoglobulin M (IgM) antibody in serum. Serologic confirmation may also be made by demonstration of a fourfold rise in IgG antibodies in acute and convalescent specimens collected 2-4 weeks later.

Supporting ExaminationChest radiographyIf bacterial pneumonia is suspected, perform chest radiography. The frequent occurrence of measles pneumonia, even in uncomplicated cases, limits the predictive value of chest radiography for bacterial bronchopneumonia.Lumbar punctureIf encephalitis is suspected, perform a lumbar puncture. CSF examination reveals the following:Increased protein Normal glucose Mild pleocytosis with a predominance of lymphocytes

ManagementManagement of measles is supportive. Maintenance of hydration, oxygenation, and comfort are goals of therapy. Antipyretics for comfort and fever control are useful.Antiviral therapy is not effective in the treatment of measles in otherwise normal patients. For patients with respiratory tract involvement, airway humidi- fication and supplemental oxygen may be of benefit. Respiratory failure due to croup or pneumonia may require ventilatory support. Oral rehydration is effective in most cases, but severe dehydration may require intravenous therapy. Vitamin A deficiency in children in developing countries has long been known to be associated with increased mortality from a variety of infectious diseases, including measles. The American Academy of Pediatrics suggests vitamin A therapy for selected patients with measles

Preventionthe measles virus vaccine is routinely administered along with the mumps and rubella vaccines as the measles-mumps-rubella (MMR) vaccine.The current recommendations include a first dose at 9 months old followed by a second dose at 24 moths old and 6 years old for measles and first dose at 15 months old and followed by second dose at 5-6 years old.Contraindications to the vaccine include immunodeficiencygeneralized cancers (eg, leukemia, lymphoma)active, untreated tuberculosistherapy with immunosuppressants. HIV infection is only a contraindication in the presence of severe immunosuppression (ie, CD4 counts lower than 15%).

ComplicationMorbidity and mortality from measles are greatest in patients < 5 years of age (especially 1 years of age) and > 20 years of age Severe malnutrition in children results in suboptimal immune response and higher morbidity and mortality with measles infection.

Pneumonia is the most common cause of death in measles. It may manifest as giant cell pneumonia caused directly by the viral infection or as superimposed bacterial infection. The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus

Subacute sclerosing panencephalitis (SSPE) is a chronic complication of measles with a delayed onset and an outcome that is nearly always fatal.It appears to result from a persistent infection with an altered measles virus that is harbored intracellularly in the CNS for several years. After 7-10 years the virus apparently regains virulence and attacks the cells in the CNS that offered the virus protection. This slow virus infection results in inflammation and cell death, leading to an inexorable neurodegenerative process.

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