PEM Case of the Week
Yvonne P. Giunta, MD, FAAP
Division Director, Department of Pediatric Emergency Medicine
12 yr old female presents to the ED for evaluation of headache, URI symptoms and fever. She is noted to have a fever in triage and she has a visible rash to her face. Parents state that she is not vaccinated. She is from Mexico, immigrated to New York a few years ago, but has never received any vaccines since birth. No recent travel and no known sick contacts.
This information alone should be enough to make you consider measles as a possibility. This patient needs to be isolated immediately. Below I will provide a summary from the CDC site and a lot more information for your reading and viewing pleasure. Most importantly, highlighted in yellow below, I provided a summary of our specific process at SIUH to make it easier if you encounter a patient like this in real time. Thank you to especially to Dr. Brian Tang for your help in a rule out measles case we had recently in our Peds ED.
From CDC site:
Between January 1 and April 4, 2025, the Centers for Disease Control and Prevention has been notified of 607 confirmed U.S. cases of measles in 22 jurisdictions and six outbreaks (defined as three or more cases), with the largest outbreak in Texas and New Mexico accounting for more than 90% of cases. Most of these cases were among children and adolescents who had not received a measles vaccine or whose vaccination history was unknown. Three measles deaths have been reported so far this year: one in an unvaccinated adult in New Mexico and two in unvaccinated school-aged children in Texas.
Measles is extremely contagious and begins with fever, cough, coryza (runny nose), and conjunctivitis (pink eye), followed 2–4 days later by a rash that starts on the face and spreads downward on the body. Infected people are contagious from 4 days before the rash starts through 4 days afterward. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes and can remain infectious in the air and on surfaces for up to 2 hours after an infected person leaves an area. Measles can cause severe health complications, including pneumonia, encephalitis, and death. MMR vaccination remains the best way to protect against measles and its complications.
If you suspect your patient has measles or was exposed to measles:
Isolate your patient with suspected measles immediately, ideally in a single-patient airborne infection isolation room, or in a private room with a closed door until an isolation room is available.
Immediately notify the Department of Health: DOH will provide guidance on testing, isolating, and managing patients with suspected measles and people exposed to measles. People exposed to measles who do not have evidence of immunity may be eligible for post-exposure prophylaxis either with MMR vaccine (within 72 hours of exposure) or immunoglobulin (within 6 days of exposure).
Collect samples: Nasopharyngeal swab for reverse transcription polymerase chain reaction (RT-PCR) testing, as well as a blood specimen for serology testing. Collecting a urine specimen along with an NP swab may improve sensitivity of testing.
Manage patients with supportive care. There is no specific antiviral therapy for measles. Medical care is supportive to help relieve symptoms. Complications, such as pneumonia and other infections, should be appropriately tested and treated. Vitamin A may be administered to patients with confirmed measles under the supervision of a healthcare provider. Overuse of vitamin A can lead to toxicity and cause damage to the liver, bones, central nervous system, and skin. Pregnant women should avoid taking high levels of vitamin A as it has been linked to severe birth defects.
In summary, if you get a patient with suspicion of measles at SIUH, this is what you have to do:
If the patient was not already identified and isolated from triage, isolate them immediately.
Call Admin on Call (Shift Admin schedule) so they can help you from the back end and start a timeline of potential contacts ASAP.
Call the Department of Health 866-692-3641 to inform them that we have a case of suspected measles and give them phone number to our lab at SIUH 718-226-9400 so the DOH can facilitate a courier to pick up the specimens.
Labs need to be drawn for In-house and Send-Out testing:
In-house: Serum Ig Roseola/Measles, RVP and any other labs pertinent based on evaluation.
Send-out (to be picked up by the DOH from the lab): Serum IgG/IgM Roseola/Measles (gold or red top tubes), Urine (sterile cup), Nasopharyngeal +/- Conjunctival PCR in viral medium (same as RVP medium)
**** in summary will need to draw TWO sets of Serum IgG/IgM, collect 2 urine specimens and 2 Nasopharyngeal swabs (one for our own lab and one for DOH). In one specimen bag place specimens for our lab to run. In another specimen bag, place specimens inside with patient label on each tube and label the bag with clear instruction that it is to be picked up by DOH.
Physician/RN/ACP should walk the specimens directly to the lab with clear instructions that the DOH samples are to be refrigerated and will be picked up by DOH who will communicate with the lab at the x9400 extension.
For Staten Island (NYC), the DOH will place the testing eOrder that will accompany the specimen. This will be held in the lab's refrigerator. Remember to label all specimens with patient sticker.
Contact ID on call (Amion schedule for peds/adult ID)
Patient admitted pending results secondary to public risk if discharged
Resources
Key Points
KEY POINTS
Measles can be severe. Since January 1, 2025, 12% of reported measles cases in the United States have been hospitalized. There have been 2 confirmed deaths from measles, and 1 death under investigation.
The risk of measles remains low for most of the United States due to high immunization coverage and rapid case identification and response efforts.
Measles, mumps, and rubella (MMR) vaccination is the best way to protect against measles and its complications.