What is the primary treatment approach for a patient with measles, considering various patient demographics and past medical histories, such as weakened immune systems due to Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) or chemotherapy?

Measles Treatment

Measles treatment is primarily supportive care, as there is no specific antiviral therapy for the disease; however, vitamin A supplementation is critical for reducing morbidity and mortality, particularly in children, and immunocompromised patients require immune globulin (IG) for post-exposure prophylaxis regardless of vaccination status. 1, 2

Primary Treatment Approach: Supportive Care

The cornerstone of measles management is supportive therapy, as no specific antiviral agent exists for measles virus 3, 4, 5:

• Hydration and nutritional support are essential, with correction of dehydration and nutritional deficiencies being fundamental to management 4
• Fever management with antipyretics as needed 3
• Treatment of secondary bacterial infections (particularly pneumonia and otitis media) with appropriate antibiotics when they occur 4, 6
• Respiratory support for patients developing pneumonia or respiratory complications 4

Vitamin A Supplementation: Critical Intervention

Vitamin A should be administered to all children with measles, as it significantly reduces morbidity and mortality 4, 5:

• This intervention is particularly important for children with nutritional deficiencies, immunocompromised states, or severe disease 4
• The World Health Organization recommends vitamin A for all measles cases in developing countries and for high-risk children in developed nations 5

Special Populations Requiring Enhanced Management

Immunocompromised Patients (HIV/AIDS, Chemotherapy)

Immunocompromised patients face severe, prolonged measles illness and require aggressive prophylaxis and monitoring 1:

• Post-exposure prophylaxis with IG is mandatory for exposed symptomatic HIV-infected and other immunocompromised persons, regardless of previous vaccination status 1
• The recommended IG dose for immunocompromised patients is 0.5 mL/kg IM (maximum 15 mL), which is double the standard dose, as usual doses may not be effective 1, 2
• This corresponds to approximately 82.5 mg/kg of IgG protein (maximum 2,475 mg) 1
• Measles may present without the typical rash in immunocompromised individuals, and patients may shed virus for several weeks after acute illness 1
• Intramuscular IG may not be needed if the patient is receiving 100-400 mg/kg IGIV at regular intervals and exposure occurs within 3 weeks of the last IGIV dose 1

Patients on Chemotherapy or Immunosuppressive Therapy

• MMR vaccine is contraindicated during active chemotherapy or immunosuppressive therapy with corticosteroids (≥2 mg/kg/day prednisone equivalent for ≥14 days), alkylating drugs, antimetabolites, or radiation 1
• Patients with leukemia in remission may receive MMR vaccine only after at least 3 months have elapsed since termination of chemotherapy 1
• For immediate protection when vaccination is contraindicated, IG must be administered as post-exposure prophylaxis 1

Pregnant Women

• Measles during pregnancy increases risks of premature labor, spontaneous abortion, and low birth weight 1, 2
• MMR vaccine is absolutely contraindicated during pregnancy due to theoretical fetal risk 1, 2
• Pregnant women exposed to measles should receive IG 0.25 mL/kg IM (maximum 15 mL) within 6 days of exposure 2

Infants and Young Children

• Infants under 12 months who are exposed should receive IG 0.25 mL/kg IM (maximum 15 mL) within 6 days of exposure 2
• Infants 6-11 months may receive MMR vaccine during outbreaks, but this dose does not count toward the routine schedule and must be followed by two additional doses 2

Post-Exposure Prophylaxis Algorithm

For Immunocompetent Contacts:

• MMR vaccine within 72 hours of exposure is the preferred intervention for susceptible contacts aged ≥6 months who can receive the vaccine 2
• If vaccination is not given within 72 hours, IG 0.25 mL/kg IM (maximum 15 mL) should be administered within 6 days of exposure 2

For Immunocompromised Contacts:

• IG 0.5 mL/kg IM (maximum 15 mL) within 6 days of exposure, regardless of vaccination status 1, 2
• This higher dose is critical because standard doses may be inadequate in this population 1

Isolation and Infection Control

Patients with measles must be isolated for at least 4 days after rash onset, as they are contagious from 4 days before rash to 4 days after rash appears 2:

• Airborne precautions with N-95 masks are required for healthcare workers 3
• Patients should be placed in airborne infection isolation rooms 3
• Unvaccinated exposed contacts must be excluded from school/work for 21 days after the last case's rash onset 2

Common Pitfalls and Caveats

• Do not delay IG administration in immunocompromised patients while awaiting vaccination decisions—these patients require IG regardless of vaccination status 1
• Do not use the standard IG dose (0.25 mL/kg) for immunocompromised patients; the dose must be doubled to 0.5 mL/kg 1
• Do not assume maternal antibodies protect all infants under 6 months—household contacts in this age group still require IG prophylaxis 2
• Do not administer MMR vaccine to patients on high-dose corticosteroids (≥2 mg/kg/day or ≥20 mg/day for ≥14 days) or other immunosuppressive therapy 1
• Remember that ribavirin has been used in severe cases, particularly in immunocompromised patients, though evidence is limited 3

Complications Requiring Specific Management

Measles complications occur in 10-40% of patients and include 1, 6:

• Pneumonia (most common cause of death): requires aggressive respiratory support and treatment of bacterial superinfection 1, 4
• Encephalitis (1 per 1,000 cases): often causes permanent brain damage and requires intensive supportive care 1, 2
• Diarrhea and otitis media: common complications requiring symptomatic treatment and antibiotics for bacterial superinfection 1, 4