What is the recommended management for an adult diagnosed with measles, considering potential complications and the need for symptom relief?

Management of Adult Measles

Adults diagnosed with measles require immediate airborne isolation with N95 respiratory protection, vitamin A supplementation (200,000 IU orally), supportive care for symptoms, and aggressive treatment of bacterial complications with antibiotics. 1, 2

Immediate Infection Control

• Isolate the patient immediately in an airborne infection isolation room for at least 4 days after rash onset, as patients remain contagious from 4 days before through 4 days after rash appearance. 1, 2
• All healthcare workers entering the room must wear N95 respirators (not surgical masks), regardless of their immunity status. 1, 2
• Only staff with documented immunity should provide direct care. 1, 2
• Immunocompromised patients may shed virus for prolonged periods and require extended isolation beyond the standard 4-day period. 2

Common pitfall: Using standard droplet precautions or surgical masks instead of airborne precautions with N95 respirators is inadequate for measles. 2

Vitamin A Supplementation (Critical Intervention)

Vitamin A supplementation is the only evidence-based intervention proven to reduce measles mortality and should never be omitted. 1, 2

Standard Dosing Protocol:

• All adults with clinical measles should receive 200,000 IU of vitamin A orally, provided they have not received vitamin A in the previous month. 1, 2
• For complicated measles (pneumonia, otitis media, croup, diarrhea with dehydration, or neurological problems), administer a second dose of 200,000 IU on day 2. 1, 2
• If any eye symptoms of vitamin A deficiency are present (xerosis, Bitot's spots, keratomalacia, or corneal ulceration), give a third dose of 200,000 IU at 1-4 weeks after the initial doses. 1, 2

Common pitfall: Vitamin A supplementation is frequently overlooked in adult measles management but is critical for reducing mortality. 2

Supportive Care and Symptom Management

• Monitor and correct dehydration with oral rehydration therapy for diarrhea. 2, 3
• Provide antipyretics for fever, avoiding aspirin in younger adults due to Reye syndrome risk. 2
• Assess nutritional status and enroll in feeding programs if indicated. 2
• Monitor for complications affecting multiple organ systems, which occur in 10-40% of patients. 4

Management of Complications

Bacterial superinfections are common and require prompt antibiotic therapy. 2, 3

Common Complications Requiring Treatment:

• Acute lower respiratory infection/pneumonia: Administer appropriate antibiotics. 2, 3
• Otitis media: Treat with standard antibiotic therapy. 3
• Secondary bacterial infections: Identify and treat promptly with antibiotics. 2, 3
• Severe diarrhea with dehydration: Provide oral rehydration therapy and monitor electrolytes. 2

Neurological Complications:

• Monitor vigilantly around day 10 for encephalitis, which characteristically presents at this time and is a serious complication. 2
• Be aware that subacute sclerosing panencephalitis can occur months to years later, affecting 4-11 per 100,000 measles-infected individuals. 2, 3
• Acute disseminated encephalomyelitis and measles inclusion body encephalitis are other potential neurological sequelae. 3

Common pitfall: Assuming the patient is "out of the woods" at 10 days—encephalitis characteristically presents around this time and requires vigilant monitoring. 2

High-Risk Populations Requiring Enhanced Management

Pregnant Women:

• Face increased risks of spontaneous abortion, premature labor, and low birth weight. 2
• Cannot receive measles vaccine due to theoretical risk to the developing fetus. 5
• Should have received immune globulin (IG) 0.25 mL/kg (maximum 15 mL) within 6 days of exposure if susceptible. 1, 2

Immunocompromised Patients:

• Should have received IG 0.5 mL/kg (maximum 15 mL) if exposed, regardless of vaccination status. 1, 2
• May require extended isolation due to prolonged viral shedding. 2

Healthcare Workers:

• Do not assume adults born before 1957 are immune—up to 9.3% of healthcare workers born before 1957 may be susceptible despite presumed immunity. 5, 2
• Healthcare workers born before 1957 should be offered vaccination during outbreaks. 5

Post-Exposure Prophylaxis for Contacts

• Administer MMR vaccine within 72 hours of exposure to susceptible adults for maximum protection. 5, 2
• If vaccination is contraindicated or more than 72 hours have passed, give IG within 6 days of exposure at 0.25 mL/kg IM (maximum 15 mL). 5, 2
• Contacts who received IG should receive measles vaccine 3 months later, after passive antibodies have disappeared. 5, 2
• Medical personnel who received post-exposure prophylaxis should be removed from patient contact for 5-21 days after exposure, as prophylaxis is not completely effective. 5

Contraindications to Measles Vaccine (Relevant for Post-Exposure Prophylaxis)

• Pregnancy (theoretical risk to developing fetus). 5
• Severe immunocompromising conditions (immune deficiency diseases, leukemia, lymphoma, generalized malignancy, or immunosuppressive therapy with corticosteroids, alkylating drugs, antimetabolites, or radiation). 5
• History of anaphylactic reaction to eggs or neomycin (requires extreme caution with protocols for vaccination). 5
• Recent receipt of IG, whole blood, or blood products containing antibody (defer vaccine for at least 6 weeks, preferably 3 months). 5

Note: HIV-infected persons and those with leukemia in remission (off chemotherapy for at least 3 months) should be vaccinated if considered susceptible. 5

Key Clinical Pearls

• There is no specific antiviral therapy for measles; management is entirely supportive with vitamin A supplementation and treatment of complications. 3
• Measles causes temporary immunosuppression, increasing susceptibility to secondary bacterial infections. 3
• The characteristic presentation includes fever with cough, coryza, and conjunctivitis, followed by a maculopapular rash that begins on the face and spreads cephalocaudally. 3, 4
• Koplik spots (pathognomonic enanthem on buccal mucosa) may appear before the rash, providing an opportunity for early diagnosis. 4, 6