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Measles Involving Hepatitis in a Traveler to China: A Case Report and Review of the Literature

Measles Involving Hepatitis in a Traveler to China: A Case Report and Review of the Literature. Heather Schlesinger, DO, CPT, MC Douglas M. Maurer, DO, FAAFP, MAJ, MC Madigan Army Medical Center Fort Lewis, Washington. Classic Measles. Incubation period Prodrome - Cough -Coryza

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Measles Involving Hepatitis in a Traveler to China: A Case Report and Review of the Literature

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  1. Measles Involving Hepatitis in a Traveler to China: A Case Report and Review of the Literature Heather Schlesinger, DO, CPT, MC Douglas M. Maurer, DO, FAAFP, MAJ, MC Madigan Army Medical Center Fort Lewis, Washington

  2. Classic Measles • Incubation period • Prodrome -Cough -Coryza -Conjunctivitis -Enanthem • Exanthem

  3. Classic Measles • Incubation period • Prodrome -Cough -Coryza -Conjunctivitis -Enanthem • Exanthem

  4. Classic Measles

  5. Case Presentation

  6. Case Presentation: History • 37 yo female presented to travel clinic regarding trip to China • Childhood immunizations up to date • Prior to her departure, patient presented to her PCM with sinus complaints • Patient given rx for amoxicillin

  7. Case Presentation: History • In China, patient developed fever, headache, and malaise • Patient started her amoxicillin • Two days later, she developed a rash on her chest and face and a cough • Seen in ER and diagnosed with sinusitis and a drug reaction • Instructed to stop the amoxicillin

  8. Case Presentation: History • Over the next two days, the rash became more confluent on her face and upper chest and spread to her trunk and arms • Patient represented to ER with HA, abdominal pain, loose stools and questionable mental status changes

  9. Case Presentation: Physical • HEENT: • Generalized facial edema and left maxillary sinus tenderness • Eyes watery, conjunctiva not injected • Oropharynx without erythema or lesions • Abd: mild diffuse tenderness, no HSM • Skin: confluent maculopapular rash on face and upper chest with additional lesions on trunk and proximal arms

  10. Case Presentation: Work-up • CT head: sinusitis • Lumbar Puncture: normal • CBC: WBC 3.6 with 43 bands • LFT: AST 528, ALT 490, GGT 295 • Admitted for further work-up

  11. Case Presentation: Course • Liver enzymes down trended • Hepatitis, EBV / CMV serologies, stool studies negative • Patient discharged on day 5 • Final diagnosis: viral exanthem vs. drug reaction, hepatitis and sinusitis

  12. Case Presentation: Follow-up • Several days later, a member of the travel group was diagnosed with measles • Serology was performed and confirmed measles in this patient • In total, three of the adults from the travel group were diagnosed with measles

  13. Discussion

  14. Measles and the Traveler • Measles vaccine was introduced in 1963 • Incidence decreased by 99% in US • Average 80 measles cases annually in the US from 1999-2003 • 30 million cases annually worldwide resulting in 454,000 deaths

  15. Measles and the Traveler • Travelers should ensure immunity • Immune if: • Documentation of physician diagnosed measles • Laboratory evidence of measles immunity • Proof of receipt of two doses of live measles vaccine **Individuals born before 1957 are not considered susceptible as most of these individuals have had measles

  16. International Adoption Trends 1990 - 2006

  17. Hepatitis and Measles • Hepatitis noted to be a complication of measles in the 1960’s • In adults, elevations in liver enzymes occurs in 56-82% of measles cases • In children, occurs in 4-31% • Liver involvement more common with more severe cases of measles

  18. Conclusion • Measles remains prevalent worldwide • Documentation of immunity should be provided before traveling • International adoption is steadily increasing • Hepatitis is a common complication • Family physicians must be alert to the possibility of measles in international travelers and the differential of hepatitis

  19. Comments? Thank you!

  20. From "Polka-Dot Puss" (1949)

  21. References Mandell, Gerald L., MD, MACP, John E. Bennett, MD and Raphael Dolin, MD. Principles and Practice of Infectious Diseases. 6th Edition. Philadelphia: Churchill Livingstone, 2005. Clinical presentation and diagnosis of measles. UpToDate online. (Accessed March 9, 2007 at http://www.utdol.com/utd/content/topic.do?topicKey=viral_in/8667&type=A&selectedTitle=1~38). PowerPoint Presentation: Acute Measles Infection in Adults Following Travel to China—2006. Thomas M. Weiser, MD, MPH, Missouri Department of Health and Senior Services State Branch, CDD, OWCD. Measles Among Adults Associated with Adoption of Children in China --- California, Missouri, and Washington, July--August 2006. MMWR. February 23, 2007 / 56(07);144-146. Fact Sheet Number 286: Measles. Revised March 2006. World Health Organization. (Accessed January 3, 2007 at http://www.who.int/mediacentre/factsheets/fs286/en/.). Papania, Mark. Health Information for International Travel, 2005-2006. U.S. Department of Health and Human Services, Public Health Service. 2005. International Adoption. US Department of State (Accessed March 9, 2007 at http://trave.state.gov/family/adoption/stats/stats_451.html). Nickell, Michael D., Preston B. Cannady, Jr., Gregory A. Schwitzer. Subclinical Hepatitis in Rubeola Infections in Young Adults. Ann Intern Med 1979;90:354-355.

  22. References, cont. Gavish, Dov, Yosef Keinman, Abraham Morag, Tova Chajek-Shaul. Hepatitis and Jaundice Associated With Measles in Young Adults. Arch Intern Med1983;143:674-677. Shalev-Zimels, Hanna, Zvi Weizman, Chaim Lotan, Dov Gavish, Zvi Ackerman, and Abraham Morag. Extent of Measles Hepatitis in Various Ages. Hepatology 1988;8:138-1139. Papadopoulou, AL, M Theordoridou, V Syriopoulou, G Mostrou and CH Kattamis. Hepatitis in Children Hospitalized With Measles: The Experience Acquired After a Greek Epidemic. Journal of Paediatrics and Child Health 2001;37:55. Photos: Tom and Jerry: http://en.wikipedia.org/wiki/Image:Tomandjerrywithmeasles.JPG. Accessed March 9, 2007. Brad Pitt, Angelina Jolie and Family: www.msnbc.msn.com/id/17499011/.Accessed March 9, 2007. Madonna and son: http://photos.ivillage.com/entertainment/starsnapshots/MADONNA_BABY_300.jpg. Accessed March 9, 2007.

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