How should I manage a patient with fever, cough, coryza, conjunctivitis and a maculopapular rash that began on the face and spread downward over several days?

Management of Suspected Measles

Immediately isolate the patient and initiate supportive care while reporting the case to public health authorities, as measles is one of the most contagious infectious diseases and requires urgent contact tracing and post-exposure prophylaxis for exposed individuals. 1

Clinical Diagnosis

The constellation of fever, cough, coryza, and conjunctivitis (the "3 Cs") followed by a maculopapular rash that begins at the hairline and spreads cephalocaudally is pathognomonic for measles. 1, 2

• The characteristic rash distribution—starting at the face/hairline and spreading downward to involve the trunk and extremities while becoming confluent—is a hallmark pattern that distinguishes measles from other viral exanthems. 1, 2

• The 4-day interval between prodromal symptoms (fever with cough, coryza, conjunctivitis) and rash onset aligns precisely with typical measles progression. 1

• Look for Koplik spots (small white spots with red halos on the buccal mucosa) during the prodromal phase, as these are pathognomonic for measles, though they may fade as the rash develops. 1

• The rash typically appears 3-4 days after fever onset, initially on the face and behind the ears, with its appearance marking the peak of symptoms. 3

Laboratory Confirmation

While clinical diagnosis is sufficient to initiate isolation and management, laboratory confirmation should be pursued:

• Obtain serology for measles-specific IgM antibody, which provides rapid confirmation. 2, 4

• Consider reverse transcriptase-polymerase chain reaction (RT-PCR) for measles virus RNA in blood or urine for definitive diagnosis. 2, 4

• A four-fold or greater increase in measles-specific IgG between acute and convalescent sera can confirm diagnosis retrospectively. 2

Immediate Management Actions

Isolation is the first priority: Place the patient in airborne isolation immediately to prevent transmission, as measles has an extraordinarily high basic reproduction number. 1

Treatment is primarily supportive:

• Provide symptomatic management of fever with antipyretics. 1

• Manage respiratory symptoms with hydration and supportive care. 1, 3

• Correct dehydration and nutritional deficiencies. 3

• Treat any secondary bacterial infections (pneumonia, otitis media) with appropriate antibiotics. 2, 3

• Administer vitamin A supplementation, particularly in children, as deficiency increases risk of blindness from corneal scarring. 5, 3

Public Health Response

Contact tracing and post-exposure prophylaxis are critical:

• Report the case immediately to local public health authorities, as measles is a notifiable disease. 1

• Identify all contacts and assess their immunity through vaccination records or serologic testing. 1

• Exposed individuals without documented immunity should receive MMR vaccine within 72 hours of exposure. 1

• For those with contraindications to vaccination (immunocompromised, pregnant women, infants <6 months), administer immunoglobulin within 6 days of exposure. 1

• Up to 5% of individuals who received only a single vaccine dose can experience primary vaccine failure, making two-dose vaccination essential for adequate protection. 1

Monitoring for Complications

Complications occur in 10-40% of measles patients and include: 2

• Pneumonitis (one of the most lethal complications) requires close respiratory monitoring. 3

• Otitis media is common and should be treated if bacterial superinfection occurs. 6

• Neurological complications include acute disseminated encephalomyelitis (ADEM), measles inclusion body encephalitis (MIBE), and subacute sclerosing panencephalitis (SSPE). 4, 6

• Monitor for acute encephalopathy, which can develop after initial improvement and presents with cognitive impairment. 4

Key Clinical Pitfalls

• Do not delay isolation while awaiting laboratory confirmation—clinical diagnosis based on the classic presentation is sufficient to initiate infection control measures. 1

• Most maculopapular rashes in measles turn hyperpigmented (89%) along the course of illness, which can aid in retrospective diagnosis. 7

• The combination of fever, maculopapular rash, and subsequent hyperpigmentation has 90.7% sensitivity for measles in outbreak settings. 7

• Measles affects multiple organ systems beyond the characteristic rash, requiring vigilant monitoring for respiratory, gastrointestinal, and neurological complications. 3, 6