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Case Presentation

Morbilli
Preceptor:

dr. Ulynar Marpaung, Sp.A


Presenter:
Fitria Nurulfath
(1102010105)
Pediatric Department
Raden Said Soekanto Hospital
Yarsi Medical University
Periode August 3rd October 11th 2015

Patient Identity
Name

: L.A

Birth Date : May 4th 2005


Age

: 10 years 3 months

Gender : Male
Address : KP TANGSI 3/6 CIKARANG. East Jakarta
Nationality : Indonesia
Religion : Moslem
Date of admission

: August 25th 2015

Date of examination : August 25th 2015

Parent Identity
Father

Mother

Name

Mr. S

Mrs. M

Age

40 years old

37 years old

Job

Employee

Housewife

Nationality

Indonesia

Indonesia

Religion

Islam

Islam

Education

High School

High School

History Taking
The

anamnesis was taken on August 25th 2015, using alloanamnesis method.

Fever since four days prior to admission at hospital.


Rash, cough, flu, headache, nausea, vomiting, diarrhea, abdominal pain

Chief complain

Additional complains :

History of Present
Illness
A 10 years old boy came to Raden
Said Sukanto Police Center Hospital
suffering from fever since four days
before admission to the hospital. This
complains also followed by rash all
over his body, cough, flu, headache,
nausea, vomiting, diarrhea, abdominal pain
since 4 days and swallowing pain since 1 day
before admission.

History of Present Illness


(2)
For the blood test results in emergency room
(25th August 2015) are Hb 12.8 g/dl, leukocytes
4.900 u/l, hematocrit 35%, trombocytes
274.000/ul, and erythrocyte 4.68 jt/ul
On the days of hospital admission, patient
condition was compos mentis. Rash, fever,
cough, flu, headache, diarrhea still exist.

History of Present
Illness

Since 4 days
before
admission the
patient had
fever, rash all
over his body

4 days before
admission the patient
had cough, flu,
headache, nausea,
vomiting, abdominal
pain, diarrhea 3 times a
day

1 day before
admission the
patient had
swallowing pain

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 History
Antenatal 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

Birth History
Labor

: Clinic

Birth attendants : Doctor


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 old
Psychomotor development
Smile
Slant

: 1 month old
: 2 months old

Speech Initation
Prone Position

: 2 months old
: 4 months old

Sitting
Crawling

: 6 months old

Standing
Walking

: 10 months old

: 8 months old
: 12 months old

Conclusion: growth and developmental is still in the normal


limits and was appropriate according to the patients age

History ofImmunization
Eating
History

Immunization Frequen
Time
Breast milk: 6 months
cy
Formula milk: SGM since t months old
0,1,6
Baby biscuit: Biscuit Milna and RegalHepatitis B 3 times
months old
Fruit and vegetables: Banana, papaya
Polio

4 times

BCG

1 time

DPT

0,2,4,6
months old

1 month
old
3 times
2,4,6
months old

Hib

3 times

2,4,6
months old

Measles

1 time

9 months
old

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


History of Disease in Other Family Members / Around the
House

Her neighbors son had measles a week


ago.

Physical Examination
Date : August 25th 2015
General Status
General condition: Mildly ill
Consciousness
: Compos Mentis
Pulse : 100x /min, regular, full, strong.
Breathing rate
: 20x /min
Temperature : 38.3oC (per axilla)

Anthropometry Status

Weight : 26 kilogram

Height

: 131 cm

Antropometry
Status
Weight : 26 kg
Height : 131 cm
Nutritional status based
NCHS 2000
(National Center for Health
Statistic) year 2000
WFA (Weight for Age)
26/31 x 100% = 83 %
HFA (Height for Age)
131/137 x100% = 95 %
WFH (Weight for Age)
26/26 x 100% = 100 %
Conclusion:

The

nutritional status.

patient

has

good

Head Toe Examination


Head
Normocephaly,
hair
(black,
normal
distribution, not easily
removed) sign of
trauma (-), rash (+)
Eyes
Icteric
sclera
-/-,
conjunctivitis
+/+,
lacrimation -/-, swollen
eyes -/-, pupils
3mm/3mm isokor, direct and indirect light
response ++/++.
Ears
Normal shape, no wound, no bleeding,
secretion or serumen -/-, rash (+)
Nose
Normal shape, midline septum, secretion -/-,

Head Toe Examination (2)


Mouth
Lips : Dry
Mucous : Moist
Tongue : Not dirty
Tonsils : T1/T1, no hyperemia
Pharynx : Hyperemia

Neck
Lymph node enlargement (+), scrofuloderma (-), rash (+)

Head Toe Examination (3)


Thorax
Inspection : symetric when breathing, retraction
(-), ictus cordis is not visible.
Palpation

: mass (-), tactile fremitus +/+

Percussion : sonor on both lungs


Auscultation
Cor
: regular S1-S2, murmur (-), gallop (-)
Pulmo : vesicular +/+, wheezing -/-, rhonchi -/Rash (+)

Head Toe Examination (4)


Abdomen
Inspection : Convex, epigastric retraction (-),
there is no widening of the veins, no spider nevi.
Palpation : supple, liver and spleen
palpable, fluid wave (-), abdominal mass (-)
Percussion:
abdomen,

The entire field


shifting dullness (-)

of

tympanic

Auscultation: normal bowel sound, bruit (-)


Rash +

not

Head Toe Examination (5)


Vertebra
There does not appear scoliosis, kyphosis, and
lordosis, do not look any mass along the line of
the vertebral
Extremities
Warm,capillary refill time < 2 seconds, edema(+)
Skin
Normal turgor, (rash +)

Neurological
Examination
Meningeal sign

Nuchal rigidity

Kernig sign

Lasegue sign

Brudzinski 1

Brudinski 2

Motoric Examination
Power

Hand

5 5 5 5/ 5 5 5 5

Feet

5 5 5 5/ 5 5 5 5

Tonus

Hand

Normotonus / Normotonus

Feet

Normotonus / Normotonus

Trophy

Hand

Normotrophy / Normotrophy

Feet

Normotrophy / Normotrophy

Motoric Examination (2)


Physiologic Reflex
Upper extrimities

Biceps

+/+

Triceps

+/+

Lower extrimities

Patella

+/+

Achilles

+/+

Motoric Examination (3)


Pathologic Reflex
Upper extrimities

Clonus

Hoffman

-/-

Trommer

-/-

Patella

-/-

Achilles

-/-

Lower extrimities

Babinsky

-/-

Chaddock

-/-

Oppenheim

-/-

Gordon

-/-

Schaeffer

-/-

Autonom
Examination
Defecation Normal ( 1-2 times daily)
Urination

Normal ( 4-5 times daily )

Sweating

Normal

Laboratory Investigation
Hematolgy

Result

Normal Value

Haemoglobin

12.8 g/dL

13-16 g/dL

Leukocytes

4.900/uL

5,000 10,000/L

Hematocrits

35 %

40 48 %

Trombocytes

274.000/ uL

150,000 400,000/L

Erythrocytes

4.68 million/uL

4 5 million/L

Working Diagnosis
Morbilli
Dd/ Rubella

Management
IVFD RL 1650cc 22dpm
Inj. Cefotaxime 2 x 1 g i.v.
Ambroxol 3 x 1 c
Sanmol 3 x 1 c
Lacto B 2 x 1 sach
Zinkid 1 x 1 c
Domperidone 2 x 1 c
Vit A 1x200.000 units

Prognosis
Quo ad vitam
: dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad
bonam

Follow Up ( August 26th 2015 )


S

Cough (+)
Rash (+)
Coryza (+)
Fever (+)

General condition: Compos Mentis


Heart rate
= 100x /min
Respiratory rate = 26x /min
Temperature = 37.5C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/Abdomen : distention (-), bowel sound (+) normal
Rash (+), Conjunctivitis (+)

Morbilli

IVFD RL 1650cc 22dpm


Inj. Cefotaxime 2 x 1 g i.v.
Ambroxol 3 x 1 c
Sanmol 3 x 1 c
Lacto B 2 x 1 sach
Zinkid 1 x 1 c
Domperidone 2 x 1 c
Vit A 1x200.000 units
Salicyl talc

Follow Up (August 27th


2015 )

Cough (+)
Rash (+)
Coryza (+)
S : Chest pain when breathing still persist but the pain is reduced,
Fever (-)
shortness of breath (-), subfebrile fever (-), dizziness (-) and cough is
reduced.

General condition: Compos Mentis


Heart rate
= 110x /min
O : Compos
Mentis
Respiratory rate = 24x /min
Pulse : 88 x/min, regular, full, strong.
Temperature
= 36C
Breathing rate
: 22x/min
Cardio
: S1/S2,
reguler, no murmur, no gallop
Temperature
: 36
C (per axilla)
: vesiculer
+/+, rhonchi
-/-, wheezing -/ Pulmo :Pulmonary
intercostal retraction
(-), vesiculer
+/+, wheezing
-/-,
rhoncy
+/+
Abdomen : distention (-), bowel sound (+) normal
Cor: S1/S2 reguler, no murmur, no gallop
Rash (+), Conjunctivitis (+)
o

A
P

Morbilli
IVFD RL 1650cc 22dpm
Cefotaxime 2 x 1 g i.v.
: Patient can Inj.
go home.
Ambroxol 3 x 1 cth
Patient is asked to check Mantoux test, then bring the result to the
polyclinic.Sanmol 3 x 1 cth
Lacto B 2 x 1 sach
Zinkid 1 x 1 cth
Domperidone 2 x 1 cth
Vit A 1x200.000 units
Salicyl talc

A : Suspect lung TB dd/ bronchopneumoni

Follow Up (August 28th


2015 )

Cough (+)
Rash (+)
Fever (-)

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

General condition: Compos Mentis


Heart rate
= 106x /min
Respiratory rate = 22x /min
Temperature
= 35.7C
O : Compos
Mentis
Pulse :Cardio
88 x/min,: regular,
strong. no murmur, no gallop
S1/S2,full,
reguler,
Breathing
rate
: 22x/min
Pulmonary
: vesiculer +/+, rhonchi -/-, wheezing -/ Temperature : 36 C (per axilla)
Abdomen : distention (-), bowel sound (+) normal
Pulmo : intercostal retraction (-), vesiculer +/+, wheezing
Rash (+), Conjunctivitis
-/-, rhoncy +/+ (+)
o

A
P

Cor: S1/S2 reguler, no murmur, no gallop

Morbilli
IVFD
1650cc 22dpm
: Suspect lung
TB dd/RL
bronchopneumoni
Inj. Cefotaxime 2 x 1 g i.v.
Ambroxol 3 x 1 cth
: Patient can go home.
Sanmol 3 x 1 cth
Patient is Lacto
asked toB
check
2 x Mantoux
1 sach test, then bring the result to the
polyclinic.
Zinkid 1 x 1 cth
Domperidone 2 x 1 cth
Vit A 1x200.000 units
Salicyl talc

Literature Review

Definition
Measles is an acute childhood infectious disease
caused by a virus. The virus is transmitted from
person to person through coughing or sneezing.
The disease is characterized by:

a generalized, reddish (erythematous),


blotchy (maculopapular) rash;
a history of fever usually above 38C (if not
measured, then "hot" to touch); and
at least one of the following - cough, runny
nose (coryza), or red eyes (conjunctivitis).

Etiology
Measles 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
Pathology
The 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

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 symptoms


high fever
enanthem cough
coryza
conjunctivitis
a prominent exanthema.
Koplik spots
diarrhea

Diagnosis
The 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
Examination
Chest radiography
If 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 puncture
If encephalitis is suspected, perform a lumbar puncture.
CSF examination reveals the following:
Increased protein
Normal glucose
Mild pleocytosis with a predominance of lymphocytes

Management
Management 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 humidification 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

Prevention

The 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


immunodeficiency
generalized cancers (eg, leukemia, lymphoma)
active, untreated tuberculosis
therapy with immunosuppressants.
HIV infection is only a contraindication in the presence of severe
immunosuppression (ie, CD4 counts lower than 15%).

Complication
Morbidity 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.