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

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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

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Classic Measles

• Incubation period
• Prodrome
• -Cough
• -Coryza
• -Conjunctivitis
• -Enanthem
• Exanthem

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Classic Measles

• Incubation period
• Prodrome
• -Cough
• -Coryza
• -Conjunctivitis
• -Enanthem
• Exanthem

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Classic Measles
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Case Presentation
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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

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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

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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

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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

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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

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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

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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

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Discussion
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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

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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

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International Adoption Trends 1990 - 2006
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Hepatitis and Measles

• Hepatitis noted to be a complication of measles
  in the 1960s
• 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

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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

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Comments?

• Thank you!

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From "Polka-Dot Puss" (1949)
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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/8667typeAselectedTitle138).
• PowerPoint Presentation Acute Measles Infection
  in Adults Following Travel to China2006. 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 197990354-355.

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References, cont.

• Gavish, Dov, Yosef Keinman, Abraham Morag, Tova
  Chajek-Shaul. Hepatitis and Jaundice Associated
  With Measles in Young Adults. Arch Intern Med
  1983143674-677.
• Shalev-Zimels, Hanna, Zvi Weizman, Chaim Lotan,
  Dov Gavish, Zvi Ackerman, and Abraham Morag.
  Extent of Measles Hepatitis in Various Ages.
  Hepatology 19888138-1139.
• 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 20013755.
• 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/entert
  ainment/starsnapshots/MADONNA_BABY_300.jpg.
  Accessed March 9, 2007.