Patient handout

Measles (rubeola) — primary measles + pneumonia + ADEM + SSPE + atypical immunocompromised + immune amnesia + post-exposure prophylaxis + MMR vaccination eligibility

PRODUCTION

1. Your condition

This handout is for measles (rubeola) — primary measles + pneumonia + adem + sspe + atypical immunocompromised + immune amnesia + post-exposure prophylaxis + mmr vaccination eligibility. Your care team identified this based on: prodrome 2-4 d: cough + coryza + conjunctivitis (the 3 c's) + fever ≥ 39 °c (often 40-40.5 °c) + malaise — measles prodrome (moss lancet 2017 pmid 28673424; aap red book 2024).

Other reasons your team may use this plan: koplik spots — clustered grayish-white papules on red base on buccal mucosa opposite molars (pathognomonic; transient 12-72 h before rash; easily missed) (moss lancet 2017; aap red book 2024); maculopapular rash beginning at hairline / behind ears / face → caudal spread (cephalocaudal) over 3 d → confluent → desquamates with hyperpigmentation (moss lancet 2017; aap red book 2024); respiratory distress / new bilateral infiltrates / spo2 < 94% in measles context — primary viral pneumonia or bacterial superinfection (aap red book 2024; idsa/ats cap 2019).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
vitamin_a_retinol	200,000 IU PO day 1 + day 2 (≥ 12 mo); 100,000 IU PO day 1 + day 2 (6-11 mo); 50,000 IU PO day 1 + day 2 (< 6 mo); third dose 2-4 wk later in clinical vitamin-A deficiency or severe protein-energy malnutrition	PO	day 1 + day 2	Reduces measles mortality ~ 30-50% in pediatric cohorts regardless of nutritional status (Imdad Cochrane 2010 PMID 21154399; D'Souza Cochrane 2002 PMID 21154399; WHO 2024; AAP Red Book 2024)

Plan: Measles supportive care + universal Vitamin A pediatric + empiric bacterial co-therapy for superinfection + empiric IV acyclovir for ADEM differential + ribavirin off-label for immunocompromised atypical measles

3. When to call your provider

Contact your care team if any of the following happen:

New respiratory distress / oxygen level (SpO₂) < 94% → urgent ED + CXR + IV acyclovir empiric + IV antibiotics if bacterial superinfection features
New neuro signs / seizures → urgent ED + MRI + LP + IV acyclovir empiric (HSV differential)
Dehydration with inability to maintain oral intake → urgent ED + IV fluids
Persistent fever > 48-72 h after rash onset → suspect bacterial superinfection → re-evaluate
Subacute neurologic decline 7-10 yr post-measles → neurology + ID + SSPE evaluation (EEG + MRI + CSF measles IgG with intrathecal antibody index)
Immune-amnesia surveillance: febrile illness in measles survivor 1-3 yr post-measles → lower threshold for empiric antibiotics + work-up other infections

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

ANY suspected/confirmed measles case → IMMEDIATE notification of state/local public health (do NOT wait for laboratory confirmation) + airborne isolation (negative-pressure room with N95 PPE) + outbreak investigation + contact tracing (4 d before rash + forward 4 d after rash); every measles case is a notifiable disease per CDC + state law (CDC ACIP; state notifiable-disease law)
Measles pneumonia with respiratory distress (oxygen level (SpO₂) < 94% OR new bilateral infiltrates OR mechanical ventilation requirement) — life-threatening; admit (ICU if respiratory failure); supportive O2 ± ventilation; empiric ceftriaxone + vancomycin for bacterial superinfection (especially MRSA, S. aureus, S. pneumoniae, S. pyogenes, H influenzae) per cross-route to pulm.cap.core.v1; continue Vitamin A pediatric (AAP Red Book 2024; IDSA/ATS CAP 2019; IDSA HAP/VAP 2016)(life-threatening)
Measles ADEM / acute postinfectious encephalitis (altered mental status, seizures, focal deficits within 2 wk of rash) — life-threatening; admit ICU; LP + CSF studies + MRI brain + EEG; empiric IV acyclovir 10 mg/kg q8h (adult) or 60 mg/kg/d divided q8h (neonate) pending HSV PCR (HSV is the major treatable mimic; do NOT delay); steroids controversial (high-dose IV methylprednisolone considered per neurology, evidence weak); ribavirin NOT effective for measles ADEM; ID + neuro consult; ~ 15% mortality + ~ 25% permanent neuro sequelae per CDC (AAP Red Book 2024; Tunkel IDSA encephalitis 2008)(life-threatening)
Susceptible pregnant patient (any trimester) exposed to measles within 6 d — IVIG 0.5 g/kg IV (max 15 g); if active disease, treat per phenotype (supportive + bacterial co-empirics if pneumonia + maternal-fetal medicine consult); MMR CONTRAINDICATED in pregnancy (live attenuated); maternal mortality elevated especially with measles pneumonia; teratogenicity controversial but less established than rubella; postpartum MMR planning (ACOG; CDC ACIP; AAP Red Book 2024)
Infant < 12 mo with measles exposure OR active disease — severe; IVIG 0.5 g/kg IV (max 15 g) within 6 d of exposure (MMR not routinely given < 12 mo; early-dose MMR at 6-11 mo for international travel + outbreak, counts as dose 0); if active disease → admit + Vitamin A age-adjusted (50,000 IU < 6 mo, 100,000 IU at 6-11 mo) + supportive + bacterial co-empirics if pneumonia features; admit threshold low; SSPE risk sharply higher in primary measles < 12 mo (~ 1 / 600 per post-elimination cohorts per Bellini JID 2005 PMID 16235165) (CDC ACIP; AAP Red Book 2024)
Immunocompromised patient (HIV CD4 < 200, transplant within 1 yr OR ongoing immunosuppression, chemo nadir, chronic high-dose steroid, primary immunodeficiency) with measles — life-threatening; atypical presentation possible (atypical rash patterns + giant-cell pneumonia + persistent shedding); high mortality (~ 10-30%); admit + ID consult + supportive + bacterial co-empirics + ribavirin off-label considered per ID (data weak — case-series only; NO FDA-approved antiviral for measles); MMR CONTRAINDICATED in severe immunocompromise (live attenuated) so IVIG is PEP option (AAP Red Book 2024; AAP Red Book 2024; IDSA)(life-threatening)
Subacute neurologic decline 7-10 yr post primary measles — cognitive decline + behavioral change + myoclonic jerks + ataxia + seizures + eventual vegetative state → SSPE (subacute sclerosing panencephalitis); life-threatening / uniformly fatal within 1-3 yr; diagnosis = clinical + EEG burst-suppression + elevated CSF measles IgG with elevated CSF:serum IgG index + MRI white-matter changes; NO curative therapy (intraventricular interferon-α + isoprinosine + ribavirin combinations explored — at best slow progression); palliative care + family education + neurology + ID consult; ~ 1 / 10,000-100,000 measles cases overall (~ 1 / 600 in primary measles < 12 mo per post-elimination cohorts); most powerful argument for universal MMR vaccination — SSPE 100% preventable by vaccination (Bellini JID 2005 PMID 16235165; Bellini JID 2005 PMID 16235165; AAP Red Book 2024)(life-threatening)

5. Follow-up

Post-measles: immune-amnesia surveillance for 1-3 yr — catch-up vaccination of all previously-incomplete routine vaccinations + close monitoring + lower threshold for empiric antibiotics in febrile illness in measles survivors (Mina Science 2019 PMID 31672891); routine pediatric vaccinations re-administered if pre-measles immunity is impaired. Post-pneumonia: respiratory recovery + lung function; ID follow-up if immunocompromised. Post-ADEM: neurology + neuropsychology + rehabilitation; ~ 15% mortality + ~ 25% permanent neuro sequelae; serial imaging + functional assessment. Post-SSPE: palliative care + family education + neurology + ID; progression to vegetative state + death within 1-3 yr. Vaccination reconciliation: MMR 2-dose pediatric schedule audit; adult catch-up; early-dose MMR for travel + outbreak; high-risk catch-up (HCW, students, international travelers, outbreak contacts). Family education + contact tracing if institutional outbreak; public health reporting through resolution.

6. Sources

Guideline: CDC ACIP — MMR Vaccination + Measles Surveillance (current 2024-2025) + CDC Measles Outbreak Response (current 2024-2025) + AAP Red Book current edition (2024 + 2026 floor) Measles chapter + WHO Measles Guidelines 2024 (universal Vitamin A regardless of nutritional status) + Moss Lancet 2017 measles review (PMID 28673424) + Mina Science 2019 immune amnesia (PMID 31672891) + Bellini J Infect Dis 2005 SSPE incidence (PMID 16235165) + McLean MMWR 2013 ACIP MMR/rubella/mumps (PMID 23760231) + Imdad Cochrane 2010 Vitamin A supplementation 6mo-5yr (PMID 21154399) + Tunkel IDSA encephalitis 2008 empiric IV acyclovir + IDSA/ATS CAP 2019 bacterial superinfection + ACOG Practice Advisory Measles in Pregnancy