A middle-aged otherwise healthy woman was admitted with fever and rash. About one month prior to presentation, she had a vesicular rash on the left upper abdomen. She was diagnosed with herpes zoster and treated with famciclovir for seven days with near resolution of rash. A few days later, she developed post-herpetic neuralgia, for which she was started on lidocaine patch, gabapentin, and as needed ibuprofen.

Two weeks prior to presentation, she went on a cruise. On returning home, she felt fatigued, which she initially attributed to the cruise and recent shingles. On the morning prior to admission, she noticed a few bumps on her forehead and face. Towards the evening, she experienced chills and was febrile to 102.4°F. Over the next 24 hours, the rash progressed cephalo-caudally to involve the torso, the back, and all four extremities prompting her to present to her primary care physician who decided to admit her to the hospital for further evaluation. Review of systems was positive for nausea, fatigue, and lack of appetite. She denied headaches, confusion, neck stiffness, cough, coryza, sore throat, dysphagia, dyspnea, myalgias or arthralgias, chest or abdominal pain, or changes in bowel or bladder habits.

Temperature 97.8°F (37.1°C), blood pressure 128/82 mm Hg, pulse 81 beats per minute, and a respiratory rate of 18 per minute. She was a good historian, lucid, alert and fully oriented. She looked uncomfortable and had mild conjunctival injection. The posterior oropharynx was erythematous but without vesicles or ulcerations. Dermatological exam was notable for a generalized eruption consisting of discrete 1-2 mm blanching macules and papules on the palms, soles, trunk, and extremities coalescing into confluent patches on the face, ears, and neck (Figures 1-5). There was mild ear and facial edema, without targetoid lesions, no blistering, and no ulcerations. She did not complain of pruritus or skin tenderness. There was hyperpigmented scarring seen at site of prior zoster. The rest of the examination was normal.

Figure 1: Photograph of her back

Figure 2: Photograph of her upper torso

Figure 3: Photograph of her right upper extremity

Figure 4: Photograph of her palms

Figure 5: Photograph of her lower extremities

Relevant laboratory findings included leukopenia with bandemia and thrombocytopenia; white blood cell count was 2,080/uL with 16% lymphocytes, 2% eosinophils, and 24% bands (reference range 4,400 – 11,300/uL) and platelets were 85 K/uL (reference range 150 – 450 K/uL). There was an increase in both aspartate aminotransferase and alanine aminotransferase, which were 91 IU/L (reference range 11 – 40 IU/L) and 155 IU/L (reference range 4 – 35 IU/L) respectively. C-reactive protein was 22.4 mg/L (reference range <5.0 mg/L). Other routine laboratory test results were normal. Chest x-ray showed no acute cardiopulmonary process.

She had a negative Human Immunodeficiency Virus (HIV) test. Hepatitis A, B, C serologies were negative. Lyme C6 peptide screen was negative. Babesia and anaplasmosis smears were negative. Parvovirus B19 IgM was negative and IgG was mildly positive. Mumps IgG was positive. Rubella IgG was negative. Coxsackie IgM and IgG were negative. Antinuclear antibodies and anti-DNA were negative. Blood cultures remained sterile. Punch biopsy of the skin revealed folliculitis with mild superficial perivascular lymphocytic inflammatory infiltrate compatible with a viral exanthem. Lack of eosinophils on biopsy argued against a drug reaction. Measles IgM and IgG antibodies resulted positive at 1.61 AU/ml (reference range 0.79 AU/ml or less) and >300.00 AU/ml (reference range 24.9 AU/ml or less) respectively. Nasopharyngeal swab for measles polymerase chain reaction (PCR) came back positive for measles virus confirming the diagnosis.

Immediately after initial suspicion of measles, patient was placed on airborne isolation and supportively managed with rest and hydration. On day 2, the diagnosis was confirmed. She improved clinically with fading of rash on day 3 of hospitalization. After speaking with State Department of Public Health, she was discharged on day 4. En route from hospital to home, she was asked to wear a regular surgical mask per infection prevention team. She did well on follow-up appointment with complete resolution of symptoms by day 7.

Further investigations revealed that one of the other members on the cruise had also been infected with measles.

Measles is a negative-stranded RNA virus that belongs to the genus ‘Morbillivirus’, hence the term morbilliform rash. The virus emerged more than 1000 years ago when our human ancestors domesticated cattle. In 1954, measles virus was first isolated from an infected boy in Children’s Hospital, Boston. In 1963, measles vaccine was licensed (inactivated killed). In 1967, our patient was born and received the vaccine at 11 months. In 1968, a more potent measles vaccine was developed (live attenuated). In 1971, MMR combination vaccine was developed. In 1978, our patient received the booster dose of MMR vaccine at 10 years of age. In 2000, endemic measles was eliminated from the United States (U.S.).[1] 

From January to September of 2019, the US Centers for Disease Control and Prevention (CDC) reported >1,200 cases of measles, making it the greatest number of cases reported in the U.S. since 1992. [2] Measles occurs in the U.S. following virus importations, primarily among unvaccinated children and young adults. It is spread via droplet nuclei when an infected person coughs or sneezes. It is the most contagious of the vaccine-preventable diseases with secondary attack rate in susceptible household contacts being 90%. Incubation period is 7-21 days. Patient is infectious from 4 days before until 4 days after onset of rash. Measles virus spreads first to local lymphoid tissue and is then disseminated throughout the blood stream through infected lymphocytes, infecting cells in almost all organ systems. The disease course begins with a prodrome of fever, malaise, Koplik’s spots, and “3 Cs” (cough, coryza and conjunctivitis). This is followed by a maculopapular rash with cephalocaudal and centrifugal spread. Complications such as laryngitis, otitis media, pneumonia, and diarrhea are seen in ~30% of cases. Subacute sclerosing pan-encephalitis (SSPE) is rare, but potentially fatal. On initial suspicion of measles, mask and promptly isolate the patient in a negative pressure room. Measles is diagnosed by IgM serology or nasopharyngeal/throat swab PCR. Treatment is usually supportive; patients typically improve less than 48 hours after rash onset. Airborne isolation is recommended for at least 4 days after rash onset. [3] Cherry et al. found that vaccine failure measles cases were less ill (as was seen in our patient) than cases that occurred in people who had not been vaccinated. [4] Clinicians should keep measles in their differential diagnosis for a patient presenting with fever and rash who is unvaccinated, has recently traveled internationally, or may have been exposed to a measles outbreak. Adherence to published vaccination schedules should be encouraged. During outbreaks, prompt reporting to health departments is crucial to prompt additional steps to protect the community. Until measles is eliminated globally, we will need to remain vigilant to contain outbreaks when they occur.

1. Goodson JL, Seward JF. Measles 50 Years After Use of Measles Vaccine. Infect Dis Clin North Am. 2015 Dec;29(4):725-43 PMID:26610423 (PubMed abstract)
2. Centers for Disease Control and Prevention. Measles Cases and Outbreaks. https://www.cdc.gov/measles/cases-outbreaks.html
3. Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502 PMID:28673424 (PubMed abstract)
4. Cherry JD, Zahn M. Clinical Characteristics of Measles in Previously Vaccinated and Unvaccinated Patients in California. Clin Infect Dis. 2018 Oct 15;67(9):1315-1319 PMID:29878209 (PubMed abstract)

ID week Fellows' Day 2019 - oral presentation

This case was contributed by:

Tulip A. Jhaveri, MD (1); Robert A. Duncan, MD, MPH (2); Anar Mikailov, MD (3); Sujit Suchindran, MD, MPH (4)

(1) Division of Infectious Diseases and Geographic Medicine, Tufts Medical Center, Boston, MA, USA

(2) Department of Infectious Diseases, Lahey Hospital and Medical Center, Burlington, MA, USA

(3) Department of Dermatology, Lahey Hospital and Medical Center, Burlington, MA, USA

(4) Department of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA

The case was originally presented at ID Week 2019, a joint effort of Infectious Diseases Society of America (IDSA), HIV Medical Association, Pediatric Infectious Diseases Society (PIDS), and the Society for Healthcare Epidemiology of America (SHEA), during an interactive session on Fellows' Day. Copyright Infectious Disease Society of America (IDSA), 2019. Used with permission.

Case #19006: When the Answer Lies in the Name [Internet]. Partners Infectious Disease Images. Available from: http://www.idimages.org/idreview/case/caseid=577.

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