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Patient
Name
Birth Date
Age
Gender
Address
: Shaafiyah
: December 21th 2015
: 2 years old
: Female
: Ketapang, Munjul
Nationality : Indonesia
Religion
: Islam
Date of admission: December 21th 2015
Date of examination: December 21th 2015
Father
Mother
Name
Mr. Agus
Mrs. Aini
Age
30 years old
26 years old
Job
Enterpreneur
Housewife
Nationality
Javanese
Javanese
Religion
Islam
Islam
Education
Earning/month
Approximately Rp.2.000.000,-
Address
Ketapang,Munjul.
ANAMNESIS
The anamnesis was taken on December 21th 2015, by alloanamnesis (from patients mother).
Chief complain : Shortness of breath 8 hours before admission to the hospital.
Additional complains : High fever, productive cough, runny nose, lose appetite, red patches
all over the body.
History Of Present Ilness
Five days before hospital admission, a 2-years-old-girl present with sudden high fever
which is going up and down but never been measured. Fever accompanied by productive
cough, runny nose and redness watery eye. She also had hoarseness on that night. History of
convulsions, loss of consciousness shiver and delirious denied. She was taking paracetamol,
but there was no significant effect.
One day before hospital admission, red patches appeared on her face and neck, not
itchy. She also present with poor feeding and irritable. History of vomit and diarrhea denied.
Then eight hours before hospital admission, the red patches spreading to thrunk, chest and
stomach with shortness of breath occurs not long after. It was accompanied by high fever
along the day.
Bacillary Dysentry
Bronchitis
Amoeba Dysentry
Pneumonia
Diarrhea
Morbilli
Thypoid
Pertussis
Worms
Varicella
Surgery
Diphteria
Brain Concussion
Malaria
Fracture
Polio
Drug Reaction
Enteritis
Birth History
Mothers Pregnancy History
The mother routinely checked her pregnancy to the midwife and Puskesmas. She denied any
problem noted during her pregnancy. She took vitamins routinely given.
Childs Birth History
Labor
: Puskesmas
Birth attendants
: midwife
Mode of delivery
: pervaginam
Gestation
: 38 weeks
Infant state
: healthy
Birth weight
: 3400 grams
Body length
: 50 cm
According to the mother, the baby started to cry and the baby's skin is red, no
congenital defects were reported
Development History
First dentition: 6 months
2
Psychomotor development
Head Up
: 1 month old
Smile
: 1 month old
Laughing
: 1- 2 month old
Slant
Speech Initation
: 4 month old
Prone Position
Food Self
Sitting
Crawling
Standing
Walking
: 5 month old
: 4 month old
: 5-6 month old
Mental Status:Normal
Conclusion: Growth and development status is still in the normal limits and was
appropriate according to the patients age
History of Eating
Immunization History
Immunization
Frequency
Time
BCG
1 time
1 month old
Hepatitis B
3 times
0, 1, 6 months old
DPT
3 times
2, 4, 6 months old
Polio
4 times
Hib
3 times
0, 2, 4, 6 months old
2, 4, 6 months old
3
Measles
Family History
Patients both parents were married when they were 26 years old and 24 years old,
and this is their first marriage.
There are not any significant illnesses or chronic illnesses in the family declared.
Childbirth
Spontan pervaginam,
1.
gestation aterm
Gender
Age
girl
2 years old
Age Died
Sumption Died
The patient lived at the house with size 10 m x 8 m together with father and mother.
There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in which 1
room is the bedroom of three of them and 1 room is for guest. There are 4 windows
inside the house. The windows are ocassionaly opened during the day.
Hygiene:
o The patient changes his clothes everyday with clean clothes.
o Bed sheets changed every two weeks.
: mild ill
: Compos Mentis
4
- Pulse
- Breathing rate
- Temperature
Antropometry Status
- Weight
- Height
: 10.5 kilogram
: 80 cm
Nutritional Status based NCHS (National Center for Health Statistics) year 2000:
a. WFA (Weight for Age): 10,5/12 x 100 % = 87.5 % (good nutrition)
b. HFA (Height for Age): 80/86 x 100 % = 93 % (good nutrition)
c. WFH (Weight for Height): 10,5/11 x 100 % = 95.5 % (normal)
Conclusion: The patient has good nutritional status.
Normocephal, hair (black, normal distributon, not easily removed ) sign of trauma (-),
Neck
Lymph node enlargement (-), scrofuloderma (-)
Thorax
:
i. Inspection : symmetric when breathing , suprasternal, intercostal
ii.
iii.
iv.
1.
2.
i.
ii.
iii.
iv.
no spider nevi.
Palpation
Percussion
Auscultation
Vertebra
: supple, liver and spleen not palpable, fluid wave (-), mass (-)
: The entire field of tympanic abdomen, shifting dullness (-)
: normal bowel sound, bruit (-)
: There does not appear scoliosis, kyphosis, and lordosis, no mass
Laboratory Investigation
Hematology December 21th 2015
Hematology
Results
Normal Value
Haemoglobin
11,8 g/dL
13-16 g/dL
Leukocytes
6.400/L
5,000 10,000/L
Hematocrits
Trombocytes
36 %
164.000/ L
40 48 %
150,000 400,000/L
Erythrocytes
4,61 million/L
4 5 million/L
Inhalation :
8
Oxygen 1 L/Mnt
NaCl 1 cc
PROGNOSIS
Quo ad vitam
: dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam
FOLLOW UP :
December 22th 2015 December 22th 2015. Second day of hospitalization, 6th day of illness
S
A
P
Bronchopneumonia
Morbili
Pro Urinalysis
IVFD RL, micro drip 14 dpm 1000cc/24 hrs
Cefotaxim injection 2x 500 mg, IV
Paracetamol syrup 3x1 cth, oral
Cetirizine syrup 3x1 cth, oral
Ambroxol syrup 3x1 cth, oral
Vit A 100.000 IV
Follow Up December 23th 2015 (3rd day of hospitalization, 7th day of illness )
S
A
P
Bronchopneumonia
Morbili
10
Follow Up December 24th 2015 (4th day of hospitalization, 8th day of illness )
S
Bronchopneumonia
Morbili
Alkalosis Respiratorik
11
Follow Up December 25th 2015 (5th day of hospitalization, 9th day of illness )
S
Bronchopneumonia
Morbili
LITERATURE REVIEW
Definition
Measles / Rubeola / Morbili / English Measles
It is an acute viral infection characterized by a final stage with a maculopapular rash
erupting successively over the neck and face, trunk, arms, and legs, and accompanied by a
high fever. caused by a virus in the family paramycovirus genus Morbillivirus
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ETIOLOGY
Measles virus is derived from the genus Morbilivirus and family Paramyxoviridae.
Wild measles virus pathogens only for primata . ape Measles can also be infected through
blood or nasopharyngeal secretions of human. Hopkins , Koplan and Hinman stated that
measles does not have reservoir in animals and does not lead to a career in humans.
Measles virion sphere -shaped , pleomorphic , and having a cover ( envelope ) with a
diameter of 100-250 nm . Virion consists of nukleocapsid ie helix of the protein RNA and
cover having short protrusions on surface . This short Tonjoian called pepfomer , and consists
of haemagglutinin ( H ) pepiomer shaped buiat and fusion ( F ) peplomer the shaped like a
bell ( dumbbell -shaped ) . Bera.t molekui of single -stranded RNA is 4.5 X 106.
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the appearance of symptoms usually prodromal about 4 days before rash onset , a minimum of two
days after the onset of rash.
PATHOPHYSIOLOGY
Maximum spread of the virus is during the prodromal ( catarrhal stage ) , through
direct contact with an infected person , through droplet ( droplet infection) that comes out
when sneezing or coughing . Infected people become contagious on days 9-10 after exposure
( start the prodromal phase ).
Focus realized that when a viral infection into the blood vessels and spread onto the
surface epithelium of the oropharynx , conjunctiva , respiratory tract , skin , bladder urinary
and bowel On day 9-10 focus of infection is in the airway epithelium and conjunctiva , one to
two layers of necrosis. At that time the virus in large quantities back into the blood vessels
and lead to clinical manifestations of the respiratory system begins with complaints of cough
and cold with conjunctival membranes which appear red . Immune response that occurs is the
process of epithelial inflammation in the system respiratory tract followed with clinical
manifestations such as high fever , the child looks severe pain and a rash that spreads
throughout the body , seemed a little ulsera on buccal mucosa called Koplik spots . Finally,
maculopapular rash appears on the to 14 after the start of infection and at the time of humoral
antibodies can be detected . Furthermore, decreased immune system , as a result of delayed
hypersensitivity response against viral antigens occurs rash on the skin , this incident does not
appear in the case of deficit - T cells .
Measles virus infects the invasion pads . respiratory tract epithelial tract from the nose
to the bottom bag'an respirat and serious . local multiplication the respiratory mucosa
immediately followed by the first in which a virus viremia spread in leukocytes paoa sistern
retikukoendotelial . After necrosis the reticuloendothelial cells sejumtah regardless back and
pass the virus viremia second . Most affected cells are monocytes . Infected tissue including
the thymus , spleen . iimfe glands , liver , skin , conjunctiva and lungs . after second viremia
occurs throughout the respiratory mucosa ter'ibat in peijalanan diseases that cause symptoms
of cough and korisa . measles can directly cause croup , bronchiolitis and pneumonia , in
addition to the the presence of respiratory damage such as edema and loss of cilia cause
complications of otitis media and pneumonia After a few days after throughout the
respiratory mucosa is involved , there arose Koplik spots and then rash on the skin . Both of
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these manifestations on microscopic examination showed multinucleated giant cells, inter and
intracellular edema , parakeratosis and dyskeratosis.
CLINICAL MANIFESTATION
The time from exposure to development of the first symptoms of measles infection
typically 8 to 12 days and from exposure to the appearance of the rash about 2 weeks. Early
appearance of diseases such as malaise , irritability , temperatures as high as 40.6 C ,
conjunctivitis with excessive lacrimation , edema of the eyelids and photophobia , and cough
heavy hard enough .
The disease is divided into 3 stages :
1. catarrhal stage ( prodromal )
This stage lasts 4-5 days . Fever is usually the first sign and settled during the
prodromal period . Heat can be peaked on day five or six that is at the peak of onset of
eruption . The temperature ranged from 38.3 C - 40 C on when the eruption of rash peak.
Sore throat , dry cough and nasal secretions often encountered during the prodromal period.
Nonpurulen conjunctivitis occurs at the end prodromal and accompanied by photophobia and
increased lacrimation . conjunctivitis will disappeared after the fever down . Spotting Koplik
is smooth white spots with thin erythematous base , which arose first in the buccal mucosa
facing towards the molars and approximately day 3 or 4 of the prodromal period can be
extended to the entire oral mucosa . Koplik spotting a sign patognomonis of measles which
usually disappears when exanthema be it is clear.
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2. Stage eruption
Symptoms in catarrhal stage increases and raised enantem in the hard palate and the
soft palate . Then occurred macular rash erythematous papules form accompanied with
increasing body temperature . The rash initially generated behind the ears , in part upper
lateral nape , along the hair , and the lower back . can occur light bleeding , itching and
swollen face . The rash reached the bottom member on day three and disappeared in the order
of occurrence. Gland enlargement can occur mandibular lymph nodes and back of the neck ,
splenomegaly , diarrhea and vomiting In measles hemorrhagic type ( black measles ) ,
bleeding can occur from the mouth , nose or colon.
3. Stage konvalensensi
Eruption is reduced and scars older color ( hyperpigmentation ) which will eventually
go away . Besides hyperpigmentation in children Indonesia often found scaly skin .
Hyperpigmentation is a symptom pathognomonic for measles . In other diseases with
erythema or exanthema skin rash disappeared without hyperpigmentation . At this stage the
temperature decreases to be normal unless there are complications.
Following an incubation period of 10-11 days during dsawali illness with fever and
malaise . Within 24 hours of going on korisa , konjungtivltis and cough . complaint The
increased tremendously , reaching a peak on day four with skin eruption . About two days
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before the rash appears Koplik spots on the buccal mucosa membranes are dealing with molar
. in The three days getting bertarnbah lesions and on the whole mucosa . fever decreased and
Koplik spots menghiiang at the end of the second day after tirnbul rash . rash form of
maculopapular eupsi redness spreading from the head ( face , forehead , hairline , ears and
neck stas ) to the extremities in 3 up to 4 days . In the next 3 to 4 days the rash fades in the
order occurrence .
Complications that occur in patients with measles can be caused by expansion of viral
infection , secondary infection by bacteria or both Kompiikasi that can occur include otitis
media , mastoiditis , obstructive pneumonia .faringitis and laryngctrakeobaronkitis .
Moreover, it can also occur complications the central nervous system such as acute and
subacute sclerosing ensefalomyelitis panencephaliiis ( SSPE ) . Adc suspected measles
complications , especially if heat lasts longer.
Other clinical manifestations of measles atypical and modified measles . Atypical
measles is happening to a person who measles virus vaccination die . After the prodromal
period of heat and pain for 1 or 2 days , a rash that starts from the extremities and can be
urticaria , maculopapular , vesicular or a combination of several form . Also obtained high
heat , extremity edema , hepatitis and sometimes pleural effusion . In measles serology
obtained liter high HI antibody . Canderung The disease is more severe than regular measles .
This die of measles virus vaccine used in 1963 to 1967 , then the consequence is that disease
in now can only be found in adults . Modified measles is mild measles because people still
have immunity to the virus , It This can occur in infants who still have measles antibodies
from mother or someone who gets gamma globulin after contact in patients measles . Clinical
symptoms can vary and some specific clinical symptoms such as prodromal , conjunctivitis ,
Koplik spots and rashes may not obtained .
Measles occurred in patients with cellular immune deficiency such as AIDS , patients
with malignancy therapy , or for any congenital immunodeficiency , tend to be more severe .
After these patients contact with measles , clinical symptoms appear is pneumonia giant cell
without preceded by a rash . In these cases the diagnosis clinical measles difficult to enforce .
Because patients with immunocompromised may also have a poor antibody response , then
the virus isolation is the only means of diagnosis . In developing countries , reported many
severe measles are possibly related to cellular immune response poor in children with
malnutrition . Measles also looked worse when occurs in adults . CDC report in 1991 that the
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incident against measles complications are more prevalent in patients with age of 20 years
than children .
DIAGNOSIS
Clinical diagnosis in classical measles with symptoms of cough , korisa , spotting
Koplik and maculopapular rash that starts on the face , easy to do . Often found leukopenia
which may be related to infection viruses and leukocytes are dead
Laboratory diagnosis is useful if the clinician rarely seen a case of measles or the
possibility of atypical measles or pneumonia and encephalitis are not evident in patients with
immunocornpromised . Measles can be diagnosed in a laboratory with virus isolation ,
identification of viral antigens in tissues infected or the serological response to the measles
virus . examination antigen can be done with immunofluorescent examination of cells derived
nasal exudate or from urine sediment . Moreover, it can also be done examination by RT PCR . Virus isolation is technically sutit done and facilities for virus isolation is not always
available . In the culture of the virus, measles virus The show , which consists of a cytopathic
effect the cells that form stars, multinucleated syncytial giant cell containing intranuclear
inclusions Examination laboratory that is often used is the serological response . against
measles virus Examination of this response is used . netrafiksasi way of complement , ELISA
( enzyme-linked assay immunoosorbent ) and HI ( Hemaglutination - inhibition ) . test
netrafisasi require virus propagation in vitro is technically difficult done , so although quite
sensitive test is rarely done . HI tests less sensitive than the neutralization but good enough if
the compared between the two Kaii testing . Diagnosis of measles if there increase in
antibody titer 4 times or more . ELISA is more sensitive and easier performed , and can also
detect specific IgE against measles virus M at acute phase . ACIP ( Advisry Committee on
Immunization Practices ) recommends that the laboratory criteria for measles is serologic
tests positive for Ig M measles or a significant increase in antibody titer or acquired measles
virus isolation . Lately also developed serological tests using saliva .
Anamnesis
The presence of continuous high fever of 38.5 C or higher with a cough , runny nose
, sore swallows , red eyes and glare when in contact with light ( photophobia ) , often
followed by diarrhea. at The 4-5 days of fever skin rash preceded by rising temperatures more
higher than the original.
Physical examination
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The discovery that is pathognomonic Koplik spots on the buccal mucosa in front third
molars. Then came a maculopapular rash that starts from the hairline in behind the ears , then
spreads to the face , neck , and finally to the extremities.
laboratory
DIFFERENTIAL DIAGNOSIS
Measles rash must be distinguished from exanthema subitum , rubella , rubeola , infections
due to enteroviruses , and adenoviruses koksaki virus, infectious mononukleus, toxoplasmosis,
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meningococcaemia , scarlet fever , rikettsia disease , serum disease , Kawasaki disease and rash due to
the drug .
TREATMENT
Measles therapy is supportive therapy are like fluids and antipyretic. Antibiotics are
given when available secondary infection with bacteria. Prophylactic antibiotics to prevent
secondary infection is not provide value and is not recommended . Meta- analysis conducted
by Frank Shann stated behwa prophylactic antibiotics are not reduce the number of measles
mortaiitas . WHO and UNICEF recommends giving vitamin A in each measles especially
when in the state of vitamin A deficiency remains a problem . dose Recommended is 100,000
IU for children aged 6 months to 1 year and 200,000 IU for children aged 1 year or Iebih .
repeated dose the next day and 4 weeks later if obtained clinical symptoms of deficiency
Giving vitamin A. Vitamin A can reduce mortaiitas and morbidity caused by measles .
The problem that often occurs in children with measles are :
a. hyperthermia
b . Less nutrients
c . The risk of complications
Measles patients without complications can be outpatient , treatment is Symptomatic with
antipyretic administration , antitussive , expectorant , and anticonvulsants when required .
Indications of hospitalization for patients with measles are hyperpyrexia (temperature >
39C) , dehydration , seizures , oral intake is difficult or complications .
Some children need supplements of vitamin A. Children with deficiency Vitamin A is
easier to infections , including measles . WHO recommend vitamin A for all children with
measles in every country where Vitamin A deficiency is a problem and is associated with
mortality . serum with a low concentration of vitamin A found in children with measles
heavy . Ribavirin is an antiviral medication , which can help cure diseases severe measles or
when a child with a weak immune system .
COMPLICATION
In measles are common resistance is decreased so as to render easy secondary
complications such as :
1. Bronkopnemonia
Bronchopneumonia may be caused by the measles virus or by pneumococcus ,
streptococcus , staphylococcus . Bronchopneumonia can cause infant mortality was young ,
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PROGNOSIS
If the patient 's general condition without disetai with complications , the prognosis is
good, but a bad prognostic in poor general condition , a child who is suffering from a chronic
illness or if there are complications . The mortality rate has decreased in recent years to a low
level in all age groups , especially the socio- economic situation improved.
PREVENTION
Measles vaccine is part of routine immunization in children . The vaccine is usually
given in combination with mumps and German measles ( MMR vaccine / mumps , measles ,
rubella ) , injected in the thigh or upper arm . If only contains measles vaccine at the age of 9
months dibeirkan . In the form of MMR , the first dose given at 12-15 months of age , the
second dose given at age 4-6 years . In addition, patients should also be advised to rest at
least 10 days and eating nutritious foods that increase body immunity .
REFERENCES
Chen S. Measles. Available online at : http://emedicine.medscape.com/article/966220overview#a6. (Last update on March 30, 2015).
WHO. Measles. Available online at : http://www.who.int/immunization/diseases/measles/en.
(Last update on Augustus 13 2015).
Centers for Disease Control and Prevention. Measles (Rubeola). Available online at :
http://www.cdc.gov/measles/about/history.html. (Last update on November 3, 2014).
Measles Y. Maldonado . In : US Wahab ( editor ) . Nelson Health Sciences Children , edition
to -15 . Jakarta : EGC , 2000. 1608-71.
Jawetz , Melnick JL , Adellberg 's EA . Measles Virus Infection . In : Brooks GF , Ornston
LN , Irawati ( editors ) . Medical Microbiology , 20th edition Jakarta : EGC , 1996.
542-47.
Soegijanto Pediatrics S. Tropical and Infectious diseases . Jakarta : Agency IDAI Publishers ,
2000. 125-40.
Tumbelaka AR , et al . Standards of Medical Care Child Health . Jakarta : Agency IDAI
publishers , 2004. 95-98.
Fennelly GJ . Measles : http://www.emedicine2006.com [accessed on December 11 2015].
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