Worth noting for the exam (potential SCE question for those doing the clinicals, or VAQ for the next written) that there is currently a spike in the number of MEASLES cases in Australia. In fact we recently had an adult measles case at work (at Royal Darwin), which caused a flurry of infection control issues in the ED.
Our case was a 40yo caucasian woman who contracted it from a friend who was visitng from the Phillipines. Illustrates the points about who is at risk, how easy it is to catch, and contact tracing.
Here’s a great short video from 6-minutes about the current measles outbreak. (Free registration required).
Here’s a quick summary:
Those aged 26-46 often only received one dose of measles vaccine, leading to incomplete cover
Cases are being being brought back by returned travellers who have been to Asia, NZ and Europe
It is VERY contagious – you don’t need direct contact, only to be in the same room as someone who has measles and you can catch it! (there have been cases of people sitting in transit lounges in airports & catching it from fellow travellers). Think of the risk in your average over-crowded ED…
In the partially vaccinated it may present in a milder form.
Usually prodrome of cough, coryza & sore red eyes, followed on day 3-4 by the rash.
Rash starts on face, moves to trunk & limbs.
Koplik’s Spots – NB these are white spots on the buccal mucosa (inside of cheek).
Often the patient will be moderately unwell, with fevers, and other viral symptoms such as GI upset.
Don’t leave the patient in the waiting room or on a corridor trolley!
They need to be urgently isolated (negative pressure preferable but not essential)
Respiratory & contact precautions for staff, (mask, gown & gloves), exclude pregnant or unimmunised staff
Try & minimise staff contacts (in our case, every nurse, med student, Resident, Registrar & some of the Consultants wanted to see the patient…!)
If in a non-negative pressure room, you need to leave that room empty for 2 hours after patient leaves.
Serology (presence of measles IgM). You may need acute & convalescent sera to detect a rise.
Measles PCR (blood)
Viral Culture (throat swab)
NB: You can’t do serology between 8 days & 8 weeks of vaccination. To make the diagnosis in the recently vaccinated you need to identify a non-vaccine strain on culture/PCR +/- have an epidemiological link to confirmed case.
Treatment is supportive, most can go home
If discharged, they need to stay isolated at home for 4 days after the rash onset.
Contact Tracing/Public Health
This is not an ED job. Notify your Infectious Diseases team, Infection Control, and the local health department. They will do the rest.
Think of measles in any question related to a young adult returned traveller (or contact of returned traveller) with a febrile illness +/- rash.
NB: Other Australian outbreaks at the moment are Pertussis and Influenza, both would make good exam questions…