What is the management approach for measles patients presenting with chorea, fever, and sore throat?

Management of Measles Patients with Chorea, Fever, and Sore Throat

Patients with measles presenting with chorea, fever, and sore throat should receive immediate vitamin A supplementation, supportive care for symptoms, and be evaluated for neurological complications, as these symptoms suggest a potentially severe form of measles with neurological involvement.

Clinical Presentation and Diagnosis

Measles typically presents with:

• High fever (≥38.3°C/≥101°F)
• Maculopapular rash lasting ≥3 days
• At least one of the "3 Cs": cough, coryza (runny nose), or conjunctivitis 1
• Koplik spots may appear before the rash

When chorea (involuntary movements) is present, this suggests neurological involvement, which is one of the most serious complications of measles. Neurological complications include:

• Acute disseminated encephalomyelitis
• Measles inclusion body encephalitis
• Subacute sclerosing panencephalitis 1

Laboratory Confirmation

• Obtain serum for measles IgM antibody testing
• If the first sample is collected within 72 hours of rash onset and is negative, obtain a second sample at least 72 hours after rash onset 2
• Consider PCR testing of throat/nasopharyngeal swabs, urine, or oral fluid for viral RNA 1
• During outbreaks, do not delay treatment while awaiting laboratory confirmation 2

Management Protocol

1. Immediate Interventions

• Administer vitamin A immediately:

  • Children >12 months: 200,000 IU orally on days 1 and 2
  • Children <12 months: 100,000 IU orally on days 1 and 2
  • For complicated measles (including neurological symptoms like chorea), give a second dose on day 2 2, 1
  • If eye symptoms of vitamin A deficiency are present, follow the extended protocol with an additional dose 1-4 weeks later 2

• Implement airborne infection control measures:

  • Place patient in an airborne-infection isolation room
  • If unavailable, place in a private room with door closed and have patient wear a mask
  • Healthcare workers should use N95 respirators 2, 1
  • Patient is contagious from 4 days before rash onset until 4 days after rash appearance 1

2. Management of Neurological Symptoms (Chorea)

• Perform neurological assessment to determine the extent of involvement
• Consider neuroimaging (CT or MRI) if available
• Consult with neurology if available
• Monitor for progression of neurological symptoms
• Provide supportive care for chorea (safe environment, sedation if severe)

3. Fever and Sore Throat Management

• Antipyretics for fever control (acetaminophen/paracetamol)
• Avoid aspirin in children due to risk of Reye syndrome
• Ensure adequate hydration
• For sore throat:
  • Saltwater gargles
  • Throat lozenges if age-appropriate
  • Monitor for bacterial superinfection

4. Monitor and Treat Complications

• Respiratory complications:

  • Monitor for pneumonia, laryngotracheobronchitis
  • Administer antibiotics for suspected bacterial pneumonia or other secondary bacterial infections 1

• Gastrointestinal complications:

  • Provide oral rehydration therapy for diarrhea
  • Monitor hydration status and electrolytes 1

• Nutritional support:

  • Monitor nutritional status, especially in undernourished children
  • Consider enrollment in feeding program if indicated 2

5. Special Considerations for High-Risk Patients

• Undernourished children:

  • Prioritize for vaccination if not already immunized
  • Undernutrition is not a contraindication but rather a strong indication for vaccination 2
  • More aggressive nutritional support

• Immunocompromised patients:

  • Consider higher dose of vitamin A
  • More vigilant monitoring for complications
  • Consider Immune Globulin (IG) if exposure is recent (within 6 days) 2, 1

Prevention for Contacts

• Identify all contacts and assess immunity status
• For non-immune contacts:
  • MMR vaccine within 72 hours of exposure may prevent or modify disease 2, 1
  • For those who cannot receive MMR, administer IG within 6 days of exposure:
    • Standard dose: 0.25 mL/kg (maximum 15 mL)
    • For immunocompromised: 0.5 mL/kg (maximum 15 mL) 2, 1
  • Quarantine unvaccinated contacts for 21 days after exposure 1

Follow-up Care

• Monitor for late-developing neurological complications for several months
• Ensure complete recovery from chorea and other neurological symptoms
• Provide appropriate rehabilitation if neurological deficits persist
• Ensure vaccination of all eligible family members and close contacts

Pitfalls and Caveats

• Do not delay treatment while awaiting laboratory confirmation during outbreaks 2
• Fever, respiratory infections, and diarrhea are not contraindications for measles vaccination in contacts 2
• Undernutrition is not a contraindication but rather a strong indication for vaccination 2
• Do not administer aspirin to children with measles due to risk of Reye syndrome
• Do not assume chorea is always due to measles - consider other causes like Sydenham's chorea if appropriate