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Vaccine-Preventable Diseases
In Pediatric Patients: A Review
Of Measles, Mumps, Rubella,
And Varicella
Abstract
Vaccine-preventable diseases such as measles, mumps, rubella, and
varicella continue to plague children and adults worldwide. Although
public health programs have helped decrease the prevalence and
sequelae of these diseases, outbreaks still occur. To limit the spread of
these diseases, emergency clinicians must be able to readily identify
the characteristic presentations of the rashes associated with measles,
rubella, and varicella, as well as the common presenting features associated with mumps. Diagnostic laboratory studies are not usually
necessary, as a complete history and physical examination usually
lead to an accurate diagnosis. Treatment for these vaccine-preventable
diseases usually consists of supportive care, but, in some cases, severe
complications and death may occur. This issue provides a review of
the clinical features, differential diagnoses, potential complications,
and treatment options for measles, mumps, rubella, and varicella.
Editor-in-Chief
Adam E. Vella, MD, FAAP
Associate Professor of Emergency
Medicine, Pediatrics, and Medical
Education, Director Of Pediatric
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY

Associate Editor-in-Chief
Vincent J. Wang, MD, MHA
Professor of Pediatrics, Keck
School of Medicine of USC;
Associate Division Head, Division
of Emergency Medicine, Children's
Hospital Los Angeles, Los Angeles,
CA

Editorial Board
Jeffrey R. Avner, MD, FAAP
Professor of Pediatrics and Chief
of Pediatric Emergency Medicine,
Albert Einstein College of Medicine,
Children’s Hospital at Montefiore,
Bronx, NY
Steven Bin, MD
Associate Clinical Professor
of Emergency Medicine and
Pediatrics, UCSF School of
Medicine; Medical Director, UCSF
Benioff Children's Hospital, San
Francisco, CA
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency Medicine
and Pediatrics, Director, Pediatric
Emergency Department, Medical
Director, Central New York Poison
Control Center, Golisano Children's
Hospital, Syracuse, NY

December 2016

Volume 13, Number 12
Author
Deborah A. Levine, MD
Clinical Associate Professor of Emergency Medicine and Pediatrics,
New York University School of Medicine, Bellevue Hospital Center,
New York, NY
Peer Reviewers
Joshua Rocker, MD
Associate Chief, Division of Pediatric Emergency Medicine;
Assistant Professor of Emergency Medicine and Pediatrics,
Hofstra Northwell School of Medicine, Cohen Children's Medical
Center, New Hyde Park, NY
Lara Zibners, MD, FAAP, FACP
Honorary Consultant, Paediatric Emergency Medicine, St. Mary's
Hospital Imperial College Trust, London, UK; Nonclinical Instructor
of Emergency Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY
CME Objectives
Upon completion of this article, you should be able to:
1.
Recognize the distinctive features of the rashes associated
with measles, rubella, and varicella infection.
2. Describe common clinical features associated with mumps
infection.
3. Identify persons at risk for severe sequelae from these viral
diseases and recommend management options.
Prior to beginning this activity, see “Physician CME
Information” on the back page.

Ilene Claudius, MD
Associate Professor, Department
of Emergency Medicine and
Pediatrics, USC Keck School of
Medicine, Los Angeles, CA

Alson S. Inaba, MD, FAAP
Garth Meckler, MD, MSHS
Pediatric Emergency Medicine
Associate Professor of Pediatrics,
Specialist, Kapiolani Medical Center
University of British Columbia;
for Women & Children; Associate
Division Head, Pediatric Emergency
Professor of Pediatrics, University
Medicine, BC Children's Hospital,
of Hawaii John A. Burns School of
Vancouver, BC, Canada
Ari Cohen, MD
Medicine,
Honolulu,
HI
Chief of Pediatric Emergency Medicine
Joshua Nagler, MD, MHPEd
Services, Massachusetts General
Madeline Matar Joseph, MD, FACEP, Assistant Professor of Pediatrics,
Hospital; Instructor in Pediatrics,
FAAP

Harvard Medical School; Fellowship
Harvard Medical School, Boston, MA
Professor of Emergency Medicine
Director, Division of Emergency
and
Pediatrics,
Chief
and
Medical
Medicine, Boston Children’s
Marianne Gausche-Hill, MD, FACEP,
Director, Pediatric Emergency
Hospital, Boston, MA
FAAP
Medicine Division, University
Medical Director, Los Angeles
James Naprawa, MD
of
Florida
College
of
MedicineCounty EMS Agency; Professor of
Attending Physician, Emergency
Jacksonville, Jacksonville, FL
Clinical Medicine and Pediatrics,
Department USCF Benioff
David Geffen School of Medicine at
UCLA, Los Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President
Associate Professor of Emergency
Medicine, Icahn School of Medicine
at Mount Sinai; Director, Pediatric
Emergency Medicine, Goryeb
Children's Hospital, Morristown
Medical Center, Morristown, NJ

Stephanie Kennebeck, MD
Associate Professor, University of
Cincinnati Department of Pediatrics,
Cincinnati, OH
Anupam Kharbanda, MD, MS
Chief, Critical Care Services
Children's Hospitals and Clinics of
Minnesota, Minneapolis, MN

Tommy Y. Kim, MD, FAAP, FACEP
Associate Professor, Loma Linda
Sandip Godambe, MD, PhD
University Medical Center and
Vice President, Quality & Patient
Children's Hospital, Department of
Safety, Professor of Pediatrics and
Emergency Medicine, Division of
Emergency Medicine, Attending
Pediatric Emergency Medicine, Loma
Physician, Children's Hospital of the
Linda, CA
King's Daughters Health System,
Melissa Langhan, MD, MHS
Norfolk, VA
Associate Professor of Pediatrics and
Ran D. Goldman, MD
Emergency Medicine; Fellowship
Professor, Department of Pediatrics,
Director, Director of Education,
University of British Columbia;
Pediatric Emergency Medicine, Yale
Research Director, Pediatric
University School of Medicine, New
Emergency Medicine, BC Children's
Haven, CT
Hospital, Vancouver, BC, Canada
Robert Luten, MD
Professor, Pediatrics and
Emergency Medicine, University of
Florida, Jacksonville, FL

Children's Hospital, Oakland, CA
Joshua Rocker, MD
Associate Chief, Division of
Pediatric Emergency Medicine;
Assistant Professor of Emergency
Medicine and Pediatrics, Hofstra
Northwell School of Medicine,
Cohen Children's Medical Center,
New Hyde Park, NY
Steven Rogers, MD
Associate Professor, University of
Connecticut School of Medicine,
Attending Emergency Medicine
Physician, Connecticut Children's
Medical Center, Hartford, CT

David M. Walker, MD, FACEP, FAAP
Director, Pediatric Emergency
Medicine; Associate Director,
Department of Emergency Medicine,
New York-Presbyterian/Queens,
Flushing, NY

International Editor
Lara Zibners, MD, FAAP, FACEP
Honorary Consultant, Paediatric
Emergency Medicine, St. Mary's
Hospital Imperial College Trust,
London, UK; Nonclinical Instructor
of Emergency Medicine, Icahn
School of Medicine at Mount Sinai,
New York, NY

Pharmacology Editor
James Damilini, PharmD, MS, BCPS
Clinical Pharmacy Specialist,
Emergency Medicine, St. Joseph's
Hospital and Medical Center,
Phoenix, AZ

Quality Editor
Steven Choi, MD
Assistant Vice President, Montefiore
Network Performance Improvement;
Director, Montefiore Institute for
Performance Improvement; Assistant
Professor of Pediatrics, Albert
Einstein College of Medicine, Bronx,
NY

Christopher Strother, MD
Assistant Professor, Emergency
Medicine, Pediatrics, and Medical
CME Editor
Education; Director, Undergraduate
Deborah R. Liu, MD
and Emergency Department
Assistant Professor of Pediatrics,
Simulation; Icahn School of Medicine
Keck School of Medicine of USC;
at Mount Sinai, New York, NY
Division of Emergency Medicine,
Children's Hospital Los Angeles,
Los Angeles, CA

Case Presentations

2013, approximately 21.5 million children did not
receive the first dose of the measles vaccine, and
60% of these children were from 6 countries—India, Nigeria, Pakistan, Ethiopia, Indonesia, and
the Democratic Republic of the Congo.1 Even in
industrialized countries with national vaccination
guidelines (eg, the United States), vaccination coverage for measles, mumps, rubella, and varicella
in school-aged children is not complete.2 Vaccine
failures, waning immunity, vaccine rejection, and
public fear have led to community outbreaks and
clinical sequelae in those exposed and affected.
This issue of Pediatric Emergency Medicine Practice
will summarize these 4 formerly common childhood diseases that can be prevented with vaccination, but may still sporadically occur. This information will enable emergency clinicians to effectively
recognize children with these diseases to ensure
appropriate treatment and decrease their spread.

A mother reports that her 3-month-old son is fussy and has
had a runny nose and fever for the past 5 days. She also
notes that the infant developed a red, raised rash initially
on his face, which spread to his abdomen and extremities
over the course of a day. The mother reports that her son
is eating less and has been breathing rapidly. The boy was
born full-term in the United States and has no past medical
history. He has had 1 vaccination at his primary care physician, at 2 months of age. The family just returned from
a trip to London a week ago, and there are no other sick
contacts in the family. The infant’s vital signs are: heart
rate, 175 beats/min; respiratory rate, 45 breaths/min; rectal
temperature, 38.3oC (101oF); and oxygen saturation, 91%
on room air. The physical examination findings demonstrate bilateral conjunctival injection with no purulent
drainage, rhinorrhea, and slightly dry lips and oral mucosa.
The infant has a blanching maculopapular exanthem to his
face, trunk, extremities, palms, and soles. Upon auscultation, he has rales at both lung bases.

A 6-month-old girl, who was born full-term, is
brought into the ED by her mother. The mother states that
her daughter has had a fever and a rash for 3 days; the
rash began on the infant’s face as “water blisters." The
mother also states that her daughter has not felt well for
the last 2 days, has had decreased urine output, decreased
activity, and has been irritable. According to the mother,
the girl is up to date with recommended vaccinations for
her age. There are no sick contacts in the family; however, the patient’s grandmother has a painful rash on her
back. The infant’s vital signs are: heart rate, 170 beats/
min; respiratory rate, 25 breaths/min; rectal temperature,
38.5oC (101.4oF); and oxygen saturation, 98% on room
air. The physical examination is significant for vesicles on
an erythematous base on the girl’s face, trunk, extremities,
and back, as well as many excoriated and scabbed lesions.
There are erythematous papules on the anterior buccal
mucosa and the posterior pharynx. The infant’s mucous
membranes are dry, her lungs are clear, and her skin is
warm. The infant is crying and her mother is having difficulty consoling her.

What is the etiology for these patients’ fever and rash?
What are the possible complications of their illnesses? Do
these patients need any diagnostic testing or specialty
consultation? Should these patients be isolated in the ED?
What treatments are indicated? Should these patients be
admitted? Should their contacts be isolated or treated?

Critical Appraisal Of The Literature
A literature search was performed in PubMed, using
the search terms measles, mumps, rubella, varicella, vaccine-preventable, and disease outbreaks. The Cochrane
Database of Systematic Reviews was searched using
the terms measles, mumps, rubella, varicella, and vitamin A. The United States Centers for Disease Control
and Prevention (CDC) and the WHO websites were
searched for relevant materials, including recent
epidemiological data. Most data about these diseases
are from case series and epidemiological reports.

Etiology And Pathophysiology
The vaccine-preventable diseases discussed in this
review—measles, mumps, rubella, and varicella—are all
viral in etiology. See Table 1 for a summary of transmission routes, incubation periods, and isolation periods of
these 4 diseases.

Table 1. Transmission Route, Incubation
Period, And Isolation Period Of VaccinePreventable Diseases

Introduction
Vaccine-preventable diseases such as measles,
mumps, rubella, and varicella continue to afflict
children in the United States and abroad. The estimate of global vaccine coverage is approximately
84% for these 4 diseases. As of 2014, 29% of the
World Health Organization (WHO) member states
(57 countries) administer the measles vaccine. In
Copyright © 2016 EB Medicine. All rights reserved.

2

Viral
Disease

Transmission
Routes

Incubation
Period
(average
days)

Isolation Period

Measles

Droplet,
airborne

10-12

4 days after rash
develops

Mumps

Droplet

16-18

5 days after
parotitis develops

Rubella

Droplet

16-18

5-7 days after rash
develops

Varicella

Droplet,
airborne,
direct contact

14-16

1-2 days prior to
rash until lesions
are crusted

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Measles
Measles, also known as rubeola, is caused by a paramyxovirus, Measles virus. It is one of the most infectious human diseases, and more than 90% of susceptible contacts will contract it when exposed. The virus
infects an individual by respiratory droplet or aerosol
spread; it remains infectious on surfaces and in the air
up to 2 hours after exposure. The virus is transmitted via respiratory alveoli and replicates in lymphoid
organs and tissues to cause systemic infections. The
strong immune response initiated after measles
infection results in lifelong immunity. Importantly, a
profound immune suppression occurs for weeks to
months after infection and is the cause for measlesassociated mortality due to bacterial superinfection.3,4

Mumps
Mumps is also caused by a paramyxovirus, Mumps virus, but it is much less infectious than measles. The rate
of transmission from an infected source is 30%. The
disease is spread via respiratory droplet and/or contact with salivary secretions, including surface transmission of droplets. The mumps virus initially invades
the respiratory tract, then penetrates the glandular
organs (such as the parotid salivary glands, pancreas,
and genital organs) as well as the central nervous system.4,5 Infection with the mumps virus usually results
in lifelong immunity, but reinfection does occur rarely.

Rubella
Rubella, also known as the 3-day measles or German
measles, is caused by a togavirus, Rubella virus. The
infection is spread via respiratory droplet. After
infection of the cells of the respiratory tract, the virus
invades lymphoid tissue, which leads to systemic
spread. During gestation, a fetus is at risk from rubella infection through placental viral transfer from
the mother, which may result in the disruption of
fetal cell growth and organogenesis. Reinfection by
the rubella virus may occur, but is usually subclinical and only diagnosed by serologic evidence.6,7

Epidemiology
Measles
In the prevaccine era, measles caused 15,000 to 60,000
cases of blindness and 2 million deaths per year.10
Death was due to pneumonia and/or encephalitis.
Young children aged < 5 years and adults aged > 20
years are at risk for complications from measles. The
measles vaccine effort began in 1963, and decreased
the disease prevalence significantly.3 In 2000, measles
was eradicated in the United States.11 It is estimated
that almost 13 million lives have been saved by vaccination against measles.12 (See Figure 1.)

Nonetheless, measles outbreaks continue to occur, even in the United States, from imported cases.
Despite national vaccine policy guidelines, vaccine
laws and legal exemptions vary from state to state.13
This leaves many children susceptible to infection. Many countries have inadequate vaccination
programs due to high costs and difficulties reaching
broad implementation. In addition, vaccine myths
(such as the nonexistent "relationship" to autism)
have dissuaded some parents from vaccinating.
There are also a number of other myths relating to
other ingredients in vaccines that have been proven
to be safe but create fear among the misinformed.
Parental refusal results in less-than-ideal vaccine

Figure 1. Estimated Number Of Deaths
Prevented By The Measles Vaccine, 2000-2013

Varicella
Varicella, also known as chickenpox, is caused by
one of the herpesviruses, Human herpesvirus 3. The
disease is spread via respiratory droplet, aerosolization of viral particles, and direct contact with viral
particles in skin lesions. Varicella enters an individual through the respiratory tract or conjunctiva. The
virus spreads from skin to liver, spleen, and sensory
ganglia. The virus can remain dormant in the sensory ganglia and reactivate at a later time. Primary
infection with varicella leads to lifelong immunity.
Latent reactivation can cause recurrent disease
(herpes zoster, or shingles). Risk factors for recurrent
disease include advanced age, immunosuppression,
intrauterine exposure to varicella, and having had
varicella infection before 18 months of age.8,9
December 2016 • www.ebmedicine.net

Centers for Disease Control and Prevention.
Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/
mm6345a5.htm
To view a full-color version of this figure and other figures in this issue,
scan the QR code below with a smartphone or tablet or go to:
https://www.ebmedicine.net/VaccinePreventableDiseases_Figures

3 Copyright © 2016 EB Medicine. All rights reserved.

Rubella

coverage among school-aged children.

Additionally, some groups of migratory populations do not get proper healthcare, and, thus, do
not get vaccinated. These various factors result in
about 50 to 100 imported cases of measles per year
in the United States.14,15 In 2011, the United States
reported 2000 measles cases in 17 outbreaks that
were largely imported as a result of travel to areas
of European outbreaks.16 The highest yearly total of
measles cases in the postvaccine era in the United
States was reported from January to May 2014. Outbreaks in 18 states, including Ohio, California, and
New York accounted for 288 cases. Sixty-nine percent of these cases were in unvaccinated individuals and 49% of the imported cases (22 of 45) were
from the Philippines.17 In the early part of 2015,
111 cases of measles were reported in 7 states in the
United States, as well as Mexico and Canada, from
an exposure in a Disney park in California. Many of
these measles cases were in children who were not
vaccinated either due to religious or philosophical
objections, or in children who were too young to
receive the vaccine.18

Globally, 20 million children contract measles
every year. Measles caused 145,700 deaths in 2013,
mostly in children aged < 5 years and those who
lived in Africa and India.10 A global partnership between the WHO, the CDC, the American Red Cross,
the United Nations, and the United Nations Children's Fund was initiated in 2001 to achieve global
elimination of measles and rubella by 2020. Other
goals of this partnership are to achieve increased
vaccine coverage to 85% and to reduce deaths from
measles by 78%.19

Rubella results in mild illness in children and adults;
however, it can be devastating for a developing
fetus. In the prevaccine era, complications from
rubella occurred, rarely, from encephalitis, neonatal
death, spontaneous abortions, and congenital rubella
syndrome (CRS). In the 1940s, CRS was described
in infants exposed to rubella in utero, usually before
20 weeks' gestation. CRS can result in miscarriage,
stillbirth, and congenital anomalies such as cataracts,
heart defects, and developmental delay. Rubella occurs worldwide, except in the United States, where no
endemic transmission occurs because of widespread
vaccination. A few cases of rubella and CRS continue
to occur in the United States due to importation from
international travel and visitors.23 The last known
case of CRS in the United Sates was in 2009.23

According to WHO statistics, worldwide,
100,000 children are born with CRS each year.6
Regions of the highest prevalence of CRS are in
Southeast Asia and Africa, where rubella vaccination
is incomplete. Vaccination policies in many countries
target only women and children, leaving the young
male population unimmunized, which then serves
as a reservoir for disease. In 2013, large rubella
outbreaks occurred in Japan (8500 cases) and Poland
(26,000 cases), with the majority of cases occurring
in susceptible adult males. This has led to approximately 10 cases of CRS in these countries, though
this may be an underestimation, since active surveillance in Poland is not in effect.24,25

Varicella
Prior to the development of the vaccine, varicella
was one of the most ubiquitous childhood diseases.
The prevalence of varicella in the United States was
so widespread that it was similar to the birth cohort
(about 4 million cases per year), translating into
almost every child contracting the disease in his or
her lifetime. This prevalence led to tens of thousands
of hospitalizations and several hundred deaths per
year from infectious sequelae. Prior to routine vaccination, almost all adults over the age of 40 years
had antibodies to varicella. In 1995, the initial vaccination program began in the United States. In 2006, a
second dose of the vaccine was added to the schedule
to improve waning immunity and prevent school
outbreaks. The current vaccination schedule has
resulted in > 90% reduction in cases (< 10 cases per
100,000 population), hospitalizations, and deaths.26,27
No studies have shown an increase in breakthrough
varicella over time after 2 doses of varicella vaccine.

Varicella continues to occur worldwide. In the
European Union, incidence rates vary from 150 to
1300 cases per 100,000 population.28 Vaccination programs are slow to be adopted in most countries due
to cost and storage/refrigeration difficulties.

Mumps
Prior to the mumps vaccination program, which began in 1967 after the mumps vaccine was licensed,
approximately 186,000 people were infected with
mumps each year in the United States. Complications were rare, but could result in permanent
deafness and death due to encephalitis. After the
vaccination program, cases in the United States
decreased by 99%. The mumps vaccine is only 88%
effective after 2 doses, which can lead to outbreaks
in crowded environments such as college dormitories and close-contact sporting events. Four
college campus outbreaks occurred in the United
States in 2014, resulting in infection of almost 1000
people.20 A mumps outbreak affected the National
Hockey League in the fall of 2014, causing player
quarantines and game cancellations.21 Mumps is
still endemic throughout the world, including in
developed nations that vaccinate. A 2013 case series
of complicated mumps in previously vaccinated
young adults in the southwest of France reported
that affected patients suffered from meningitis,
orchitis, and hearing impairment.22
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Presenting Clinical Features
Measles
Measles typically begins with a high fever and the
3 Cs: cough, coryza (rhinitis), and conjunctivitis. An
enanthem of punctate white papules on the buccal
mucosa behind the first and second molars, called
Koplik spots, appears prior to the start of the rash.
The exanthem begins days after the prodrome in a
cephalocaudal fashion, with the head first, then the
trunk, and then the extremities. (See Figure 2.) The
infectivity of disease occurs from 4 days prior to the
onset of the rash to the fourth day of the rash.29,30

Complications associated with measles include
immune suppression due to loss of delayed-type hypersensitivity activation, which leads to secondary
bacterial infections such as otitis media and pneumonia.4,30,31 Mortality is typically due to pneumonia
and encephalitis. Otitis media is the most common
complication, occurring in 1 out of every 10 children
infected with measles. Blindness due to corneal infection, perforation, and scarring is another common
complication in those with vitamin A deficiency.

Figure 2. Measles Rash


Acute encephalitis occurs in 1 out of every 1000
cases and may result in permanent neurologic damage. In 5 to 10 cases per million, the uniformly fatal
degenerative neurologic disease, subacute sclerosing
panencephalitis, can occur 7 to 10 years after measles
infection.32,33

Mumps
Classically, mumps presents as parotitis, either
unilateral or bilateral, with tenderness and swelling at the angle of the jaw. (See Figure 3.) Preceding
glandular swelling is a prodrome of nonspecific
symptoms such as malaise, headache, and low-grade
fever. Notably, one-third of mumps cases are asymptomatic.34 Children with mumps are contagious for a
5-day period after the onset of parotitis.35

Complications associated with mumps include
aseptic meningitis, epididymo-orchitis and oophoritis in postpubertal patients, sensorineural hearing
loss, myocarditis, arthritis, arthralgia, and nephritis.
Orchitis can occur in conjunction with parotitis or
alone. Sterility is rare, but subfertility may occur in
13% of patients with mumps-associated orchitis. In
males, abnormalities of spermatogenesis can occur
in 50% of patients up to 3 months after recovery
and testicular atrophy can occur in 30% to 50% of
affected testicles.36

Rubella
Rubella can present without any symptoms at all or
with a mild, nonspecific prodrome of fever, malaise,

Figure 3. Swollen Area Under The Jaw And In
The Cheeks Of A Child With Mumps

Centers for Disease Control and Prevention/NIP/Barbara Rice.
Available at: http://phil.cdc.gov/phil/details.asp?pid=132

December 2016 • www.ebmedicine.net

Centers for Disease Control and Prevention.
Available at: http://phil.cdc.gov/phil/details.asp?pid=130

5 Copyright © 2016 EB Medicine. All rights reserved.

anorexia, conjunctivitis, coryza, lymphadenopathy
(classically, posterior chain-suboccipital and postauricular), and pharyngitis. A maculopapular rash of
rose-pink coalescing macules appears for a median
of 3 days.

Complications associated with rubella infection are few, but may include arthralgia and frank
arthritis. Rubella is the leading cause of preventable
congenital defects. Rubella infection during the first
trimester can lead to miscarriage, stillbirth, and
low birth weight.37 Approximately 85% of fetuses
exposed to the rubella virus in the first trimester
will develop some type of birth defect. CRS presents
with dermal erythropoiesis skin lesions (so-called
”blueberry muffin“ skin lesions), developmental disabilities, heart defects, cataracts, and deafness. (See
Figure 4.) Encephalitis and Guillain-Barré syndrome,
as well as thrombocytopenic thrombotic purpura
and hemolytic anemia, are rare complications.7

acute cerebellar ataxia, seizures, meningitis, encephalitis, acute disseminated encephalomyelitis, and
bacterial superinfection.40,41 A surveillance study
from Europe found a low rate of complications,
8.5 per 100,000 cases. Of 119 patients with severe
complications, neurologic complications occurred in
61% (mostly older children), followed by bacterial
skin superinfections in 26%, with infectious complications more commonly seen in children aged < 4
years.40 Neonates who develop infection within the
first 2 weeks of delivery are at highest risk for complications and death. Complications usually occur
within the first week of exanthem.

Differential Diagnosis
Measles, rubella, and varicella can present with a rash
and fever. There is some variability to the timing of
each sign and symptom. Each exanthem has classic
clinical features, but some similarities may exist. Varicella typically presents as a vesicular exanthem, but it
can be macular as well as pustular, depending on the
stage of the crop of lesions. Measles, rubella, and vari-

Varicella
Varicella begins as erythematous macules on the head
that spread to the trunk and extremities in a centripetal fashion. These macules then progress to papules,
and then to clear vesicles and pustules on top of this
erythematous base (described as “dew drop on rose
petal” lesions). (See Figure 5.) The exanthem consists
of approximately 200 to 500 lesions in 2 to 4 successive crops. Fever can last for 2 to 4 days and precede
or follow the rash.38 Varicella in a previously vaccinated patient, known as “breakthrough disease,“ usually
presents with reduced fever (afebrile or lower degree
of fever) and fewer lesions. The clinical presentation
can range from mild exanthem to disseminated infection affecting multiple organ systems.39 Patients with
varicella remain infectious until all the lesions are
crusted (about 4-5 days).

Complications of varicella infection include

Figure 5. Varicella Exanthem

Figure 4. Infant With Congenital Rubella
Syndrome

Centers for Disease Control and Prevention/Dr. Andre J. Lebrun.
Available at: http://phil.cdc.gov/phil/details.asp?pid=713

Copyright © 2016 EB Medicine. All rights reserved.

Centers for Disease Control and Prevention.
Available at: http://phil.cdc.gov/phil/details.asp?pid=6121

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cella exanthems are not petechial or purpuric, which
can differentiate them from other life-threatening
etiologies, such as meningococcemia. Fever may precede or follow the onset of the rash. In measles and
rubella, fever typically precedes the onset of a maculopapular rash. Table 2 (page 8) lists potential etiologies in the differential diagnosis for these diseases.

Parotitis is usually associated with mumps, but
may be caused by other viruses (eg, Epstein-Barr,
parainfluenza, influenza A, coxsackieviruses, human
immunodeficiency virus, human herpesvirus 6, and
adeno-associated viruses), bacteria (eg, Staphylococcus, Streptococcus, and anaerobic and gram-negative
pathogens), fungal and mycobacterial etiologies,
drugs (eg, iodides and phenothiazines), malnutrition, air insufflation, cysts, and stones.42

Prehospital Care
Emergency medical services may be utilized to
transport an infant or child with a fever and rash to
a medical facility. Assessment of the airway, breathing, and circulation, as well as vital signs, is of utmost
importance in the initial evaluation of the patient.
Patients with rapidly progressive bacterial infections,
such as bacteremia or pneumonia, or those with
evidence of dehydration or overwhelming sepsis may
deteriorate quickly and require intravenous therapy
and/or ventilatory support. Most children with
simple viral or inflammatory diseases will not need
such interventions. Prehospital providers should protect themselves from patients with fever and rash by
wearing masks and gloves until a definitive diagnosis
is made. Decontamination of ambulance of surfaces
should be completed after transport.

Emergency Department Evaluation
History
Taking a complete history of the patient's signs and
symptoms can aid the diagnosis of vaccine-preventable
diseases. The following questions should be asked:
• When did the fever start in relation to the rash?
• How did the rash spread? Did it start on the face
and move caudally or appear on the extremities?
• What did the initial rash look like? This is important, since excoriation can lead to changes in appearance, and some rashes will evolve with time.
• Did the rash occur in crops, as in varicella?
• Is the rash pruritic or tender?
• Are any prodromal symptoms present (eg, vomiting, diarrhea, cough, coryza, or conjunctivitis)?
• Are any respiratory symptoms present? Measles
and varicella can lead to pneumonia.
• Is the patient's mental status altered? Is the patient
irritable, lethargic, or confused? This can suggest
meningitis or encephalitis, or poor perfusion and
overwhelming sepsis.
December 2016 • www.ebmedicine.net

• Are there any sick contacts at home, school, or
daycare?
• Have the patient or the patient's contacts traveled
recently, either within the United States or abroad,
including industrialized nations?
• Is the patient up to date on vaccinations? Being
fully vaccinated does not preclude susceptibility to
infection.
• Are there any comorbid conditions? These may include prematurity, history of respiratory or cardiac
issues, recent or chronic steroid use, or acquired or
congenital immunodeficiencies.
• Is the patient pregnant? Fetal complications such
as congenital malformation syndromes, miscarriage, and fetal demise as well as respiratory
complications in pregnant women can occur when
a patient is infected with rubella or varicella.

Physical Examination
General Examination
Vital signs should be obtained as part of the physical examination. The physical examination should
include a thorough examination for any mucosal involvement such as vesicles, Koplik spots, or exudate
on the palate, tongue, or posterior pharynx. The oral
mucous membranes should be noted as moist or dry.
The conjunctiva should be examined for erythema or
discharge. Tympanic membranes can have decreased
mobility and erythema in the case of otitis media.
The face and neck should be examined to assess for
parotid swelling and cervical lymphadenopathy.
The neck should be examined for stiffness and range
of motion to assess for meningeal signs. The skin
should be evaluated for lesions, which should be
noted as vesicular, macular or papular, and blanchable or not. The distribution of the skin rash should
be noted, whether any sparing occurs (palms, soles,
genitalia, etc), and whether different stages of lesions exist. Capillary refill and distal pulses should
be documented. Dehydration is a common complication of illness in young children and may present
with tachycardia. Hypotension can be a late sign
of hypovolemia in pediatric patients. Lung fields
should be auscultated to listen for rales associated
with clinical pneumonia. In mumps-associated
oophoritis, the abdominal examination can be abnormal, with localized pain in the lower quadrants and
pelvic area. Genital examination should include
testicular examination to exclude orchitis.
Presentations Associated With Vaccine-Preventable
Diseases
A patient with measles will appear ill and be highly
febrile, with coryza, conjunctivitis, and a maculopapular rash that began on the face and neck that
spread downward and outward. Patients with
mumps may have mild respiratory symptoms or notable enlargement of their salivary glands. Patients
7 Copyright © 2016 EB Medicine. All rights reserved.

Table 2. Differential Diagnosis Of Fever And Rash
Life-threatening Causes

Clinical Presentation

Infectious Causes

Clinical Presentation

Meningococcemia

• Petechial purpuric rash on
trunk, extremities, and mucous
membranes, sparing the palms and
soles
• Ill-appearing
• Diffuse erythematous rash
resembling sunburn
• Associated hypotension and
multiple organ system failures
• Petechiae, usually on extremities
and mucous membranes
• Splinter hemorrhages
• New or changed heart murmur
• Macules progressing to petechiae
on wrists, ankles, palms, and soles
that spread centrally to trunk,
extremities, and face
• Thrombocytopenia
• Leukopenia
• Elevated transaminitis
• Myalgia
• Headache
• Widespread skin denudement; total
body surface area: TEN > 30%;
SJS < 10%
• Mucous membranes involvement in
90% of cases
• Fever

Scarlet fever
(group A
Streptococcus)






Primary herpes

• Painful vesicular rash on erythematous base to single
anatomical area
• Fever, malaise

Fifth disease
(Human parvovirus)

• "Slapped-cheek" appearance to face
• Lacy, reticular rash

Roseola

• Diffuse maculopapular rash, sparing face, after
resolution of fever

Epstein-Barr

• Maculopapular eruption to trunk and upper extremities,
then to face
• Fever
• Enlarged lymph nodes
• Pharyngitis

Enteroviruses,
echoviruses,
coxsackieviruses

• Maculopapular eruption to trunk, face, and extremities
• Sometimes vesicles surrounded by red halo on hands
or feet
• Oral ulcers
• Fever
• Conjunctivitis

Smallpox

• Maculopapular rash in mouth and on face and
extremities that becomes opaque, filled blisters with a
dimple in center, all in the same stage
• Fever, malaise, myalgia

Inflammatory Causes

Clinical Presentation

Lyme

Kawasaki

• Macular, morbilliform, or targetoid
rash on trunk and extremities,
associated with erythema of
palms and soles
• Periungual desquamation
• Fissured lips
• Strawberry tongue
• Conjunctival injection

• Erythematous macule at the site of tick bite that
expands with central clearing
• Fever, malaise

Chikungunya

• Morbilliform eruption on trunk and extremities; less
commonly on face
• Associated fever and disabling arthritis

Secondary syphilis

• Brownish-red maculopapular rash on head, neck,
palms, and soles 2 weeks after primary chancre

Scabies

• Pruritic papules in intertriginous areas, genitalia,
chest, and abdomen
• Associated gray lines of the burrowing insect

Impetigo

• Erythematous papules that evolve into vesicles that
rupture, leaving a honey-colored crusted exudate over
erosion; usually on face and extremities

Typhoid fever

• Rose spots (small, blanching pink papules on anterior
trunk, proximal extremities, back) occurring in groups
of 5-20, lasting 3-4 days
• Associated fever, abdominal pain, headache, malaise

Ehrlichiosis

• Maculopapular or petechial rash to body, but may
spread to palms and soles, sparing face; nonpruritic
• Erythroderma may be present with desquamation
• Associated fever, headache, malaise, conjunctivitis,
vomiting, diarrhea

Dengue

• Maculopapular or morbilliform rash to face, thorax, and
flexor surfaces; spares palms and soles
• Rash may coalesce to form islands of skin sparing
• Facial flushing may be present prior to rash
• Petechial eruption may signify hemorrhagic
complications
• Associated fever, headache, retro-orbital pain,
myalgia, nausea, and vomiting

Staphylococcal /
streptococcal toxic shock
syndrome
Bacterial endocarditis

Rocky Mountain spotted
fever

Toxic epidermal necrolysis
(TEN)/Stevens-Johnson
syndrome (SJS)

Rheumatic fever

Serum sickness

• Erythema marginatum (transient
macular lesions with central
clearing) on extensor area of
proximal extremities and trunk
• Polymorphous (urticaria,
scarlatiniform or morbilliform) rash
on abdomen, then to extremities;
not on mucous membranes
• Associated arthralgia, edema

Erythema multiforme

• Target-shaped erythematous
macules with dark purpuric
centers or pale center on
extremities, face, trunk; symmetric;
mucous membrane involvement

Langerhans cell
histiocytosis

• Reddish-brown papules
• Nodules under skin
• Pinkish scaly, crusted papules or
ulcers that may occur anywhere on
body (including the groin and scalp)
• Mucous membranes may be
involved as well as the bone,
spleen, lungs, liver, and central
nervous system

Copyright © 2016 EB Medicine. All rights reserved.

8

"Sandpaper" rash to the trunk, face, and extremities
Perioral pallor
Desquamation
Pharyngeal erythema

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with rubella have a mild prodrome with an erythematous maculopapular rash that starts on the face and
spreads in a generalized manner, with enlargement
of the posterior auricular or suboccipital lymph
nodes. A patient with varicella will present with fever and malaise and a generalized pruritic vesicular
eruption in varying stages of development.

Diagnostic Studies
The diagnosis of measles, mumps, rubella, and varicella should be made clinically. When the diagnosis
is in doubt or confirmation is needed for epidemiologic purposes, the diagnosis can be confirmed with
laboratory studies. Diagnostic tests are the same
for measles, mumps, rubella, and varicella. Viruses
can be isolated from saliva, urine, cerebrospinal
fluid, and, in the case of mumps, seminal fluid. Viral
cultures can be used for confirmation, but these are
time-consuming and expensive. Most specimens
are tested using polymerase chain reaction, which
allows for rapid, sensitive, and specific confirmation.
A limited window of opportunity may exist for viral
identification; detection may be more opportune
during the first week of illness.22 Elevated serum
viral-specific immunoglobulin M (IgM) levels or
a 4-fold rise in titers between acute and convalescent blood specimens for levels of immunoglobulin
are found in acute illness.43 Serum IgM titer interpretation is often difficult in a vaccinated patient.
Vaccinated patients may also have elevated immunoglobulin levels that may not allow for discrimination of primary infection versus reinfection versus
reactivation.44 This discernment is necessary only for
epidemiological purposes or for treatment of exposed household contacts who are at risk. A Tzanck
smear is a reliable, easy, and inexpensive technique
that can be performed on fluid from a vesicular rash,
such as in varicella; however, this method cannot
distinguish between varicella and herpesvirus.45
Routine serum blood work is sometimes not conclusive in the workup of these viruses. An elevated
white blood cell count may be seen with viremia as
well as secondary bacterial infection. Conversely, a
low white blood cell count may represent viral suppression or overwhelming sepsis. Serum chemistries
may be abnormal in patients with dehydration.

Reporting Diagnosed Cases
Measles, mumps, rubella, and varicella are all
notifiable diseases and are reportable. Emergency
clinicians who require guidance can call their local
Department of Health for advice on confirmatory
testing. Confirmation is essential for all suspected
cases, sporadic and epidemic. Laboratories should
report positive results to local Departments of
Health, who will forward this information to the
CDC for surveillance and outbreak control.
December 2016 • www.ebmedicine.net


Once a patient has been diagnosed with measles,
mumps, rubella, or varicella, the patient and family contacts should be isolated immediately. Each of
these diseases represents a public health threat, especially to high-risk populations who may be in the
emergency department. The infection control team
and the local Department of Health can be resources
for containing the spread of these diseases and can
recommend treatment options.

Treatment
General Treatment
For measles, mumps, and rubella, treatment is mainly
supportive: hydration, nutrition, and oxygen, if necessary. There is no role for antivirals in the treatment of
these diseases. Antibiotics should be prescribed for
identified presumed bacterial complications of each
viral infection, such as otitis media and pneumonia.
However, antibiotics should not be prescribed to
prevent these secondary infections. Analgesia and
antipyretics should be used to relieve pain and fever.
Typically, acetaminophen and ibuprofen are used to
relieve pain and fever associated with these viruses.
Stronger analgesics (such as opioids) may be necessary for moderate to severe pain, but they can cause
sedation and respiratory depression in high doses.
Respiratory complications are common and are a major cause of morbidity and mortality. If tachypnea or
hypoxia is present, oxygen should be administered.
Another common complication with any pediatric
disease process is dehydration. Oral, nasogastric,
or intravenous hydration should be instituted, as
indicated, in patients with a history of poor feeding,
diarrhea, vomiting, or decreased urination or physical
signs of dry mucous membranes, delayed capillary
refill, or concentrated urine.

Disease-Specific Treatment
Measles
Measles infection decreases serum levels of retinol or
vitamin A, presumably by immunological suppression, increased urinary and gastrointestinal losses,
and epithelial damage during illness.46 Studies have
shown that vitamin A supplementation can decrease
morbidity and mortality associated with measles.47
The WHO recommends high-dose vitamin A supplementation given daily for 2 consecutive doses.48
Postexposure prophylaxis with immunoglobulin
is indicated within 10 days of exposure to measles
in certain high-risk patient populations, such as
patients aged < 1 year, pregnant patients, or immunocompromised patients.49
Mumps
Parotitis and orchitis can be painful, and analgesia may be indicated. Steroids should be avoided
in mumps orchitis because steroids may decrease
9 Copyright © 2016 EB Medicine. All rights reserved.

Clinical Pathway For Managing Pediatric Patients Presenting
With Signs Of Measles, Rubella, And Varicella
Rash with or without prodrome
(fever and/or cough, coryza,
conjunctivitis) and suspicion of a
vaccine-preventable disease

Maculopapular exanthem;
cephalocaudal spread

Vesicular exanthem;
centripetal spread

Measles

Rubella

Varicella

• Isolate the patient
• Notify (via telephone or website)
the local DOH and hospital infection
control for suspected and confirmed
cases
• Administer supportive treatment
• Administer vitamin A
• Administer immunoglobulin within 10
days for high-risk patients
(Class II)

• Isolate the patient
• Notify (via telephone or website)
the local DOH and hospital infection
control for suspected and confirmed
cases
• Administer supportive treatment
• Counsel, if pregnant
(Class II)

• Isolate the patient
• Notify (via telephone or website)
the local DOH and hospital infection
control for suspected and confirmed
cases
• Administer supportive treatment
• For high-risk patients, administer
acyclovir
• For high-risk patients, administer
immunoglobulin within 96 hours to
10 days
(Class II)

Abbreviation: DOH, Department of Health.

Class Of Evidence Definitions
Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness

Level of Evidence:
• One or more large prospective studies
are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive and
compelling

Class II
• Safe, acceptable
• Probably useful

Level of Evidence:
• Generally higher levels of evidence
• Nonrandomized or retrospective studies:
historic, cohort, or case control studies
• Less robust randomized controlled trials
• Results consistently positive

Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments

Level of Evidence:
• Generally lower or intermediate levels of
evidence
• Case series, animal studies,
consensus panels
• Occasionally positive results

Indeterminate
• Continuing area of research
• No recommendations until further
research

Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2016 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2016 EB Medicine. All rights reserved.

10

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testosterone concentrations, worsening testicular
atrophy.22 There is evidence that Interferon-alfa-2b
treatment may help with symptoms and sequelae of
orchitis.22,50 There is no role for postexposure prophylaxis with immunoglobulin for mumps, though
a third dose of measles-mumps-rubella (MMR)
vaccine may have benefits in reducing outbreaks in
vulnerable populations.51 However, intravenous immunoglobulin is indicated for certain autoimmune
complications such as Guillain-Barré syndrome,
idiopathic thrombocytopenic purpura, and postinfectious encephalitis.
Rubella
Rubella treatment is supportive. There is no role for
postexposure prophylaxis to prevent rubella, even
when a patient is exposed during pregnancy.
Varicella
Patients at high risk for complications associated
with varicella include unvaccinated household contacts, pregnant patients or contacts, patients aged
> 12 years, patients on aspirin or steroids, or patients
with pulmonary or skin disorders. These patients
can be treated with the antiviral drug acyclovir
within 24 hours. Famciclovir and valacyclovir are
licensed for treatment of varicella in adults only.
Varicella immunoglobulin can be given to pregnant
patients without evidence of immunity, immunocompromised patients without evidence of immunity, or newborns and premature infants of mothers
with signs and symptoms of varicella around the
time of delivery within 96 hours or up to 10 days
after exposure.52,53

Adverse Events Associated With Vaccination
The best strategy to prevent infections from occurring is through vaccination.54 (See Table 3.) Vaccinations have great benefit to individuals as well as
communities at large. Emergency clinicians should
be aware of potential adverse effects from vaccines
and should make patients aware of both the benefits
and risks to avoid public distrust and refusal to vaccinate. The efficacy of the MMR vaccine is 97% after
2 doses, and evidence suggests that the measles,
mumps, rubella, and varicella (MMRV) vaccine, a
live attenuated vaccine, has equal efficacy.

The MMR vaccine has common adverse events

Table 3. Recommended Vaccination
Schedule For Measles, Mumps, Rubella, And
Varicella
Vaccine

Recommended Age

Measles, mumps, rubella (MMR)

First dose: 12-15 months
Second dose: 4-6 years

Varicella

First dose: 12-15 months
Second dose: 4-6 years

December 2016 • www.ebmedicine.net

associated with its administration, such as fever 6 to
12 days after vaccination, rash, joint symptoms, or
transient mild allergic reactions.55 The 2011 Institute of Medicine Consensus report found evidence
to support a causal relationship between the MMR
vaccine and inclusion body encephalitis in immunocompromised children, anaphylaxis in allergic patients (1 per 1 million doses), and febrile seizures.56
There have been some reports of thrombocytopenic
purpura after vaccination.57 The MMRV vaccine
has a higher risk of fever and febrile seizure during
the 5 to 12 days after the first dose compared to the
combination of the MMR and varicella vaccine.58

Thimerosal is a mercury-containing preservative
that was used in vaccines since the 1930s. Although
there is no evidence of harm at the low doses present
in vaccines (except mild local reactions such as redness), its use was eliminated in 2001.59

For the varicella vaccine, the adverse event rate
following immunization is 53 per 100,000 doses. The
most commonly reported adverse events are rash,
fever, and redness at the injection site. The rash associated with vaccination is contagious and isolation precautions should be followed until all lesions
are crusted or no new lesions have occurred for 24
hours. Rarely, pneumonia, hepatitis, severe rash,
or meningitis may occur. The Institute of Medicine
committee found a causal relationship between the
varicella vaccine and disseminated infection resulting in pneumonia, meningitis, and hepatitis in individuals with immunodeficiencies, as well as varicella vaccine strain viral reactivation and disseminated
infection without other organ involvement.60,61
There is moderate association of the varicella vaccine
and thrombocytopenic purpura (< 1% incidence) in
children aged 11 to 17 years.57

Special Circumstances
Patients At High Risk For Severe Disease
Special consideration should be given to patients
who are at risk for severe disease. Infants aged < 1
year, immunocompromised patients, and pregnant
women can have greater morbidity and mortality
when infected with any of these viruses. Varicella
infection may also result in severe disease in adults
aged > 20 years. While 5% of varicella cases occur in
adults, adult infections (especially in patients who
develop pneumonia) account for 35% of the mortality from this disease.62 Atopic diseases may predispose patients to severe manifestations of varicella,
especially bacterial superinfection.62

Pregnant women may develop severe disease
manifestations from infection with these viruses,
such as pneumonia, hepatitis, and sepsis. Prenatal
complications such as spontaneous abortions, preterm labor, and intrauterine death can occur. Fetal
complications such as low birth weight and congeni11 Copyright © 2016 EB Medicine. All rights reserved.

tal anomalies can occur in congenital varicella and
rubella syndromes.63

should be offered to pregnant women to potentially
decrease the likelihood of fetal infection if termination of pregnancy is not considered. For healthy,
unvaccinated people aged > 12 months, exposure to
a varicella rash requires vaccination within 5 days
of exposure. Susceptible individuals at high risk for
severe disease (eg, immunocompromised patients,
pregnant women, and infants without immunity)
should receive varicella zoster immunoglobulin
as soon as possible after exposure, up to 10 days
postexposure. Acyclovir may be indicated for
these high-risk groups, though benefits are limited.
Acyclovir should be administered within 24 hours
of the onset of a varicella rash. Healthcare workers exposed to these diseases need to be treated as
above and should remove themselves from patient
care until the incubation period passes.34,64,65

Management Of Contact Exposure
The potential consequences of patients' contacts
or caregivers being exposed to one of the vaccinepreventable diseases should be considered. Patients
suspected of having a vaccine-preventable disease
should be isolated to reduce the chance of transmission to susceptible individuals. Patients who
have been exposed to measles should be vaccinated
within 72 hours after exposure and should be
given immunoglobulin within 6 days of exposure if
they are unvaccinated, aged < 1 year, pregnant, or
immunocompromised. No postexposure prophylaxis is warranted with exposure to mumps, since
it has been found to be ineffective in preventing
disease. Individuals exposed to rubella should be
vaccinated within 72 hours and immunoglobulin

Risk Management Pitfalls In Patients With Measles,
Mumps, Rubella, And Varicella (Continued on page 13)
1. “The whole waiting room was coughing and
sneezing. I didn’t think to isolate this child.“
Patients with measles, mumps, rubella, or
varicella should be isolated, since their
respiratory droplets and secretions can be
spread to other patients, hospital staff, and
family members. Patients infected with measles
need airborne precautions for 4 days after they
develop a rash. All heathcare personnel should
follow respiratory control precautions when
treating a patient with measles. Exposed staff
or family members should be offered postexposure prophylaxis if they cannot provide
evidence of immunity against measles.

3. “I just vaccinated my patient, but I realized I
forgot to ask if she may be pregnant.”
With mumps and measles viruses, the risk to a
fetus is only theoretical. Rubella and varicella
vaccination during pregnancy harbors a
small, but real, risk for developing CRS (1.2%)
and congenital varicella infection. Routine
termination of pregnancy is not recommended,
but counseling about possible risks of infections
should be given.6,70 Vaccinations should be up
to date in women of child-bearing age and their
sexual partners.
4. “I assumed the newborn patient with a rash
contracted it from a contact. I didn’t think to
ask the mother if she had varicella near the
time of delivery.”
Newborn infants exposed to varicella whose
mothers do not have evidence of immunity or
whose mothers develop varicella 5 days before
or 2 days after delivery are at risk for severe
disease, which can lead to death. These infants
require varicella immunoglobulin.52,53,71

2. “The adolescent patient with varicella had her
newborn and her grandmother with her while
in the ED. Since the patient did not need to be
hospitalized, I went ahead and discharged her
so they could all go home.”
Family members who are at risk for vaccinepreventable diseases should be vaccinated as
soon as possible within 5 days after exposure
to the rash, in hopes of averting or modifying
the disease currently or in future exposures.
Susceptible varicella contacts should be offered
varicella zoster immunoglobulin within 10
days of exposure if they are unable to receive
the vaccine.70 Susceptible contacts with measles
exposure should also be offered intramuscular
immunoglobulin or postexposure prophylaxis
within 72 hours.33 There is no role for
postexposure prophylaxis for mumps or rubella.
Copyright © 2016 EB Medicine. All rights reserved.

5. “The patient with mumps did not require
hospitalization, so I discharged her without
follow-up.”
Hospital infection control and local and state
Departments of Health need to be notified in
order to track and notify potential contacts
of communicable disease for containment of
the spread of measles, mumps, rubella, and
varicella.
12

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Controversies And Cutting Edge
Medical literature, the Institute of Medicine (a
nonprofit, nongovernmental organization), and
national organizations such as the CDC have rejected
any causation between autism and the MMR vaccine.50,66-69 The controversy began from a disputed
paper published in 1998 that was based on a small
case series linking the MMR vaccine to autism. The
paper was retracted due to inconsistencies in the data
and conflicts of interest of the primary author, and the
medical license of the primary author was revoked.
Subsequently, no study has duplicated these findings.
Well-designed epidemiologic studies of national and
international databases have not found any evidence
for an association between the MMR vaccine and
autism. There also appears to be no plausible biologic
mechanism for this association. A recent study also
examined the relationship of the number of antigens

the body makes in response to the numerous vaccines
given in the first 2 years of life and found no difference between children without autism and those with
autism.68 The thimerosal additive in the MMR vaccine was also posited to be a possible contributor to
autism, but this has never been shown. This additive
has now been removed from most vaccines, but only
to reduce mercury exposure in children. Despite all
of the supporting data, some parent advocate groups
still contend the association between vaccines and autism, and, thus, refuse vaccination, thereby increasing
the population of unvaccinated children worldwide
and reducing herd immunity.

Disposition
Measles, mumps, rubella, and varicella are highly
contagious diseases and are potentially harmful to
unimmunized, immunocompromised, and preg-

Risk Management Pitfalls In Patients With Measles,
Mumps, Rubella, And Varicella (Continued from page 12)
6. “I didn’t want the patient with measles to
develop an ear infection, so I prescribed him
antibiotics.”
Antibiotics are not recommended to prevent
the bacterial complications of measles, such as
pneumonia and otitis media. Antibiotics are
indicated for the treatment of overt infection, but
more evidence from high-quality randomized
controlled trials is needed to recommend the
types of antibiotics, the duration of treatment,
and the day of initiation.72 While administration
of antibiotics is not recommended, 2 doses of
vitamin A is recommended to prevent ocular
complications in patients with measles.
7. “I didn’t think to ask if any of the family members of the patient with rubella may be pregnant.”
Congenital rubella infection occurs with
maternal infection during the first 20 weeks of
pregnancy. Infection may cause miscarriage,
stillbirth, and low birth weight.37 Rubella
infection may be mild and may not be evident
unless titers are performed. A pregnant woman
should be informed of the exposure and
potential harm it may cause the fetus. Close
follow-up with obstetrics is vital.

9. “I wanted to discharge the patient with varicella as quickly as possible to limit the chance
of spreading the disease, so I discharged him
home even though he wouldn’t drink anything
in the ED.”
Dehydration is a complication of any childhood
disease, especially in patients who have signs
of poor oral intake, decreased urine output, and
other fluid losses such as vomiting or diarrhea.
Physical examination should include evaluation
of mucous membranes, heart rate, capillary
refill, palpation of peripheral pulses, and the
presence of tears. Patients with dehydration
should be hospitalized with isolation
precautions.
10. “The only travel our patient had was to Europe. I didn’t think these diseases could be
contracted there.”
Patients may be at risk for vaccine-preventable
diseases throughout the world. Developed
countries such as those of Eastern Europe, the
United Kingdom, France, and Japan may be
sources for infection. A thorough travel history
is important when evaluating for a potential
communicable disease. This information may be
cross-referenced with outbreak information from
the WHO and CDC.

8. “The patient was fully vaccinated, so I did not
think he could have measles.”
Vaccination does not provide absolute coverage
against disease. The MMR vaccine is about
95% effective in preventing measles and 88%
effective in preventing mumps after 2 doses.67
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13 Copyright © 2016 EB Medicine. All rights reserved.

nant contacts. It is important that patients remain
isolated, whether at home or in the hospital; that
susceptible contacts (and, potentially, the patient) are
vaccinated; and that infection control and the local
Department of Health are notified. While measles
requires airborne and droplet precautions, mumps
and rubella require droplet precautions. Varicella
requires airborne, droplet, and contact precautions
until the lesions have crusted. Infants with CRS require contact precautions until nasopharyngeal and
urine cultures are negative. Patients with respiratory
distress, dehydration, refusal to take oral liquids,
or those at risk for severe disease (such as immunocompromised or pregnant patients) should be
hospitalized with isolation precautions.

lic health issue; thus, isolation and control measures
and vaccine education are paramount to limiting the
spread of these diseases.

Case Conclusions
The cephalocaudal distribution of the 3-month-old boy's
rash was typical for measles. The child also displayed the
classic prodrome of conjunctivitis, coryza, and cough. The
physical examination was significant for rales, indicating a respiratory process that is commonly associated
with measles. The patient was sent for a chest radiograph
that confirmed pneumonia. You consulted with infection
control, the infectious disease service, and the Department of Health to prevent the spread of the disease within
the boy’s family, the hospital, and the community. The
infant was treated with antibiotics for typical pathogens
responsible for pneumonia and with 2 doses of vitamin
A to reduce ophthalmologic sequelae. He was admitted
to the hospital due to ill appearance, hypoxemia, and
increased work of breathing. The patient was isolated, and
the family contacts were advised on incubation period and
symptoms of measles, should they become infected. Per
the Department of Health, no one required postexposure
prophylaxis.

You diagnosed the 6-month-old girl with varicella with
clinical evidence of moderate dehydration. The infant’s rash
was pathognomonic for varicella due to crops of vesicular
lesions in different stages appearing in centripetal distribution. The infant had evidence of dehydration by history and
on physical examination of mucous membranes. She did
not exhibit any bacterial infection or evidence of nervous
system involvement. You called infection control to aid
with containing the spread of the disease within the girl's
family and the hospital. The patient was isolated. The
infant was not treated, since the illness began more than
24 hours earlier, and the patient had no known risk factors
for severe disease. You advised the parents of the patient to
seek immediate medical care and treatment with acyclovir if
worsening symptoms were to appear. The patient was given
oral rehydration in the ED; when she was tolerating fluids
well, she was discharged home with close follow-up with
her primary care physician. The patient’s contacts were
counseled regarding their exposure and risk of developing
varicella. All contacts reported previous infection or vaccination and none were at high risk for complications, so no
interventions were necessary.

Time- And Cost-Effective Strategies
• Measles, mumps, rubella, and varicella usually
require only supportive care; antiviral medications are not indicated in patients who are not
considered to be at high risk. Prescribe antibiotics only if there is evidence of bacterial superinfection, as antibiotics will not prevent secondary
infections.
• Patients with communicable illnesses do not
need hospitalization unless indicated. Patients
who are very young and display signs of respiratory distress, toxicity, or dehydration require
inpatient hospitalization. Many infants and
children with these vaccine-preventable diseases
are well appearing and well hydrated and need
only close follow-up by caregivers and primary
care providers.
• Laboratory testing is unnecessary in patients
with measles, mumps, rubella, and varicella
unless the history and physical examination suggest bacterial infection, bleeding disorder, dehydration, or other abnormality. Viral confirmation
via laboratory testing (serology, polymerase
chain reaction, culture) is done only when diagnosis is not clear clinically or for epidemiologic
purposes.

Summary
Outbreaks of measles, mumps, rubella, and varicella still occur in the United States, and emergency
clinicians must remain vigilant in diagnosing these
diseases. Emergency clinicians should be able to recognize these diseases based on rash morphology and
potential risk factors (eg, travel, lack of full vaccination, etc). Vaccinations should be encouraged, since
they are highly effective in reducing these diseases
and their associated complications. Cases of these
vaccine-preventable diseases can usually be managed with supportive care, but severe complications
and death may occur. The greatest threat is the pubCopyright © 2016 EB Medicine. All rights reserved.

References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.

To help the reader judge the strength of each
reference, pertinent information about the study, such
14

Reprints: www.ebmedicine.net/pempissues

as the type of study and the number of patients in the
study is included in bold type following the references,
where available. The most informative references cited
in this paper, as determined by the authors, are noted
by an asterisk (*) next to the number of the reference.
1.

Centers for Disease Control and Prevention. Measles and
rubella move fast. Measles & Rubella Initiative: a global partnership to stop measles & rubella. Available at: http://www.
cdc.gov/globalhealth/measles/pdf/measles-factsheet2015.
pdf. Accessed November 14, 2016. (Expert review)

2.

Seither R, Masalovich S, Knighton C, et al. Vaccination coverage among children in kindergarten — United
States, 2013–14 school year. MMWR Morb Mortal Wkly Rep.
2014;63(41):913-920. (Prospective database report)

3.

de Vries RD, Mesman AW, Geijtenbeek TB, et al. The
pathogenesis of measles. Curr Opin Virol. 2012;2(3):248-255.
(Review)

4.

Naim HY. Measles virus. Hum Vaccin Immunother.
2015;11(1):21-26. (Review)

5.

Vareil MO, Rouibi G, Kassab S, et al. Epidemic of complicated mumps in previously vaccinated young adults in the
South-West of France. Med Mal Infect. 2014;44(11-12):502-508.
(Retrospective case series; 7 patients)

6.

Centers for Disease Control and Prevention. Rubella. Epidemiology and prevention of vaccine-preventable diseases.
Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/rubella.html. Accessed November 14, 2016. (Review)

7.

Banatvala JE, Brown DW. Rubella. Lancet.
2004;363(9415):1127-1137. (Review)

8.

World Health Organization. Varicella and herpes zoster vaccines: WHO position paper, June 2014. Wkly Epidemiol Rec.
2014;89(25):265-287. (Position paper)

9.

Centers for Disease Control and Prevention. A new product
(VariZIG) for postexposure prophylaxis of varicella available
under an investigational new drug application expanded access protocol. MMWR Morb Mortal Wkly Rep. 2006;55(8):209210. (Fact sheet)

10. World Heath Organization. Measles. Available at: http://
www.who.int/mediacentre/factsheets/fs286/en/. Accessed
November 14, 2016. (Fact sheet)
11. Katz SL, Hinman AR. Summary and conclusions: measles
elimination meeting, 16-17 March 2000. J Infect Dis. 2004;189
Suppl 1:S43-S47. (Review)
12. Elam-Evans LD, Yankey D, Singleton JA, et al. National,
state, and selected local area vaccination coverage among
children aged 19-35 months - United States, 2013. MMWR
Morb Mortal Wkly Rep. 2014;63(34):741-748. (National surveillance data)
13. National Vaccine Information Center. Vaccine laws. Available at: http://www.nvic.org/vaccine-laws.aspx. Accessed
November 14, 2016. (Fact sheet)
14. Whitaker JA, Poland GA. Measles and mumps outbreaks in
the United States: think globally, vaccinate locally. Vaccine.
2014;32(37):4703-4704. (Editorial)
15. Macartney K. Prevention of varicella: time for two-dose
vaccination. Lancet. 2014;383(9925):1276-1277. (Editorial
comment)
16. Centers for Disease Control and Prevention. Measles
- United States, 2011. MMWR Morb Mortal Wkly Rep.
2012;61(15):253-257. (Surveillance data)
17. Gastanaduy PA, Redd SB, Fiebelkorn AP, et al. Measles United States, January 1-May 23, 2014. MMWR Morb Mortal
Wkly Rep. 2014;63(22):496-499. (Prospective case series)
18. Clemmons NS, Gastanaduy PA, Fiebelkorn AP, et al. Measles

December 2016 • www.ebmedicine.net

- United States, January 4-April 2, 2015. MMWR Morb Mortal
Wkly Rep. 2015;64(14):373-376. (Prospective case series)
19. World Health Organization. Global measles and rubella strategic plan: 2012-2020. Available at: http://www.measlesrubellainitiative.org/wp-content/uploads/2013/06/MeaslesRubella-Strategic-Plan.pdf. Accessed November 14, 2016.
(Strategic plan)
20. Centers for Disease Control and Prevention. Mumps cases
and outbreaks. Available at: http://www.cdc.gov/mumps/
outbreaks.html. Accessed November 14, 2016. (Prospective
case series)
21. Klein J. Mumps outbreak prompts NHL teams to
take precautions. Available at: http://www.nytimes.
com/2014/12/07/sports/hockey/mumps-outbreakprompts-nhl-teams-to-take-precautions.html?_r=0. Accessed
November 14, 2016. (News report)
22. Hviid A, Rubin S, Muhlemann K. Mumps. Lancet.
2008;371(9616):932-944. (Review)
23.* Papania MJ, Wallace GS, Rota PA, et al. Elimination of
endemic measles, rubella, and congenital rubella syndrome
from the Western hemisphere: the US experience. JAMA
Pediatr. 2014;168(2):148-155. (Expert review)
24. Centers for Disease Control and Prevention. Nationwide
rubella epidemic--Japan, 2013. MMWR Morb Mortal Wkly
Rep. 2013;62(23):457-462. (Prospective case series)
25. Centers for Disease Control and Prevention. Rubella and
congenital rubella syndrome control and elimination global progress, 2000-2012. MMWR Morb Mortal Wkly Rep.
2013;62(48):983-986. (Worldwide surveillance data)
26.* Marin M, Meissner HC, Seward JF. Varicella prevention
in the United States: a review of successes and challenges.
Pediatrics. 2008;122(3):e744-e751. (Review)
27. Centers for Disease Control and Prevention. Evolution of
varicella surveillance--selected states, 2000-2010. MMWR
Morb Mortal Wkly Rep. 2012;61(32):609-612. (Surveillance
data)
28. European Centre for Disease Prevention and Control. Varicella vaccination in the European Union. Stockholm, Sweden: ECDC Guidance: January 2015. Available at: http://
ecdc.europa.eu/en/publications/Publications/VaricellaGuidance-2015.pdf. Accesssed November 14, 2016. (Review)
29. Tannous LK, Barlow G, Metcalfe NH. A short clinical review of vaccination against measles. JRSM Open.
2014;5(4):2054270414523408. (Review)
30. Centers for Disease Control and Prevention. Measles. Epidemiology and prevention of vaccine-preventable diseases.
Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html. Accessed November 14, 2016. (Review)
31. Griffin DE. Measles virus-induced suppression of immune
responses. Immunol Rev. 2010;236:176-189. (Review)
32. Gahr P, DeVries AS, Wallace G, et al. An outbreak of
measles in an undervaccinated community. Pediatrics.
2014;134(1):e220-e228. (Prospective case series; 21 patients)
33. Centers for Disease Control and Prevention. Measles (rubeola). Available at: http://www.cdc.gov/measles/hcp/
index.html. Accessed November 14, 2016. (Review)
34. American Academy of Pediatrics. Mumps. In: Pickering L,
Baker C, Kimberlin D, et al, eds. Red Book: 2009 Report of the
Committee on Infectious Diseases. 28th ed. Elk Grove Village,
IL: American Academy of Pediatrics; 2009:468-472. (National
recommendations)
35. Centers for Disease Control and Prevention. Updated recommendations for isolation of persons with mumps. MMWR
Morb Mortal Wkly Rep. 2008;57(40):1103-1105. (Review)
36. Davis NF, McGuire BB, Mahon JA, et al. The increasing incidence of mumps orchitis: a comprehensive review. BJU Int.

15 Copyright © 2016 EB Medicine. All rights reserved.

2010;105(8):1060-1065. (Review)

demiology and prevention of vaccine-preventable diseases.
Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/mumps.html. Accessed November 14, 2016. (Review)

37.* Thompson KM, Simons EA, Badizadegan K, et al. Characterization of the risks of adverse outcomes following rubella
infection in pregnancy. Risk Anal. 2016;36(7):1315-1331.
(Systematic review)

56. Maglione MA, Das L, Raaen L, et al. Safety of vaccines
used for routine immunization of US children: a systematic
review. Pediatrics. 2014;134(2):1-13. (Systematic review)

38. Centers for Disease Control and Prevention. Varicella. Epidemiology and prevention of vaccine-preventable diseases.
Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/varicella.pdf. Accessed November 14,
2016. (Review)

57. O’Leary ST, Glanz JM, McClure DL, et al. The risk of
immune thrombocytopenic purpura after vaccination in
children and adolescents. Pediatrics. 2012;129(2):248-255.
(Retrospective case series; 197 patients)

39. Speer M. Varicella-zoster infection in the newborn. UpToDate.
Available at: http://www.uptodate.com/contents/varicellazoster-infection-in-the-newborn. Accessed November 14,
2016. (Review)

58. Marin M, Broder KR, Temte JL, et al. Use of combination
measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization
Practices (ACIP). MMWR Recomm Rep. 2010;59(Rr-3):1-12.
(Expert review)

40. Ziebold C, von Kries R, Lang R, et al. Severe complications of
varicella in previously healthy children in Germany: a 1-year
survey. Pediatrics. 2001;108(5):E79. (Surveillance study)

59. Centers for Disease Control and Prevention. Thimerosal in
vaccines. Vaccine safety 2015. Available at; http://www.
cdc.gov/vaccinesafety/Concerns/thimerosal/. Accessed
November 14, 2016. (Expert review)

41. Science M, MacGregor D, Richardson SE, et al. Central nervous system complications of varicella-zoster virus. J Pediatr.
2014;165(4):779-785. (Prospective case series; 84 patients)

60. Institute of Medicine of the National Academies. Varicella
virus vaccine. In: Stratton K, Ford A, Rusch E, et al, eds.
Adverse Effects of Vaccines: Evidence and Causality. Washington, DC: The National Academies Press; 2011:239-292. (IOM
review)

42. Baszis K, Toib D, Cooper M, et al. Recurrent parotitis as a
presentation of primary pediatric SjÖgren syndrome. Pediatrics. 2012;129(1):e179-e182. (Cases series; 4 patients)
43.* Centers for Disease Control and Prevention. Control and
prevention of rubella: evaluation and management of suspected outbreaks, rubella in pregnant women, and surveillance for congenital rubella syndrome. MMWR Recomm Rep.
2001;50(Rr-12):1-23. (National recommendations)

61.* Black S, Shinefield H, Ray P, et al. Postmarketing evaluation
of the safety and effectiveness of varicella vaccine. Pediatr Infect Dis J. 1999;18(12):1041-1046. (Retrospective case control;
89,753 patients)

44. Centers for Disease Control and Prevention. Interpreting
laboratory tests. Chickenpox (varicella). Available at: http://
www.cdc.gov/chickenpox/hcp/lab-tests.html. Accessed
November 14, 2016. (Review)

62. Liese JG, Grote V, Rosenfeld E, et al. The burden of varicella
complications before the introduction of routine varicella
vaccination in Germany. Pediatr Infect Dis J. 2008;27(2):119124. (Prospective nationwide surveillance; 918 patients)

45. Oranje AP, Folkers E. The Tzanck smear: old, but still of inestimable value. Pediatr Dermatol. 1988;5(2):127-129. (Review)

63. Cohen A, Moschopoulos P, Stiehm RE, et al. Congenital varicella syndrome: the evidence for secondary prevention with
varicella-zoster immune globulin. CMAJ. 2011;183(2):204208. (Systematic review)

46. West CE. Vitamin A and measles. Nutr Rev. 2000;58:S46-S54.
(Review)

64. American Academy of Pediatrics. Measles. In: Pickering L,
Baker C, Kimberlin D, et al, eds. Red Book: 2009 Report of the
Committee on Infectious Diseases. 28th ed. Elk Grove Village,
IL: American Academy of Pediatrics; 2009:444-455. (National
recommendations)

47.* Imdad A, Herzer K, Mayo-Wilson E, et al. Vitamin A
supplementation for preventing morbidity and mortality in
children from 6 months to 5 years of age. Cochrane Database
Syst Rev. 2010(12):CD008524. (Systematic review)
48. World Health Organization. Vitamin A supplements: a guide
to the treatment and prevention of vitamin A deficiency and
xerophthalmia. Second edition. Geneva: WHO, 1997.(Guidelines)

65. American Academy of Pediatrics. Rubella. In: Pickering L,
Baker C, Kimberlin D, et al, eds. Red Book: 2009 Report of the
Committee on Infectious Diseases. 28th ed. Elk Grove Village,
IL: American Academy of Pediatrics; 2009:579-584. (Guidelines)

49. Young MK, Nimmo GR, Cripps AW, et al. Post-exposure passive immunisation for preventing measles. Cochrane Database
Syst Rev. 2014(4):CD010056. (Systematic review)

66. Uno Y, Uchiyama T, Kurosawa M, et al. The combined
measles, mumps, and rubella vaccines and the total number
of vaccines are not associated with development of autism
spectrum disorder: the first case-control study in Asia. Vaccine. 2012;30(28):4292-4298. (Prospective case-control study;
189 patients)

50. Yapanoglu T, Kocaturk H, Aksoy Y, et al. Long-term efficacy
and safety of interferon-alpha-2B in patients with mumps
orchitis. Int Urol Nephrol. 2010;42(4):867-871. (Prospective
interventional study; 37 patients)
51. Fiebelkorn AP, Lawler J, Curns AT, et al. Mumps postexposure prophylaxis with a third dose of measles-mumps-rubella vaccine, Orange County, New York, USA. Emerg Infect Dis.
2013;19(9):1411-1417. (Prospective case control; 239 patients)

67.* Demicheli V, Rivetti A, Debalini MG, et al. Vaccines for
measles, mumps and rubella in children. Cochrane Database
Syst Rev. 2012(2):CD004407. (Systematic review)
68. DeStefano F, Price CS, Weintraub ES. Increasing exposure
to antibody-stimulating proteins and polysaccharides in
vaccines is not associated with risk of autism. J Pediatr.
2013;163(2):561-567. (Retrospective case-control study; 256
children, 752 controls)

52.* Centers for Disease Control and Prevention. Updated recommendations for use of VariZIG--United States, 2013. MMWR
Morb Mortal Wkly Rep. 2013;62(28):574-576. (Expert review)
53. Bapat P, Koren G. The role of VariZIG in pregnancy. Expert
Rev Vaccines. 2013;12(11):1243-1248. (Review)

69. Jain A, Marshall J, Buikema A, et al. Autism occurrence by
MMR vaccine status among US children with older siblings
with and without autism. JAMA. 2015;313(15):1534-1540.
(Retrospective cohort study; 95,727 children)

54. Centers for Disease Control and Prevention. Recommended
immunization schedules for persons aged 0 through 18 years,
United States, 2015. Available at: http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combinedschedule.pdf. Accessed November 14, 2016. (Review)

70.* Marin M, Guris D, Chaves SS, et al. Prevention of varicella:
recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(Rr-4):1-

55. Centers for Disease Control and Prevention. Mumps. Epi-

Copyright © 2016 EB Medicine. All rights reserved.

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Reprints: www.ebmedicine.net/pempissues

40. (National recommendations)
71. Centers for Disease Control and Prevention. Managing people at risk for severe varicella. Chickenpox (varicella). Available at: http://www.cdc.gov/chickenpox/hcp/persons-risk.
html. Accessed November 14, 2016. (Expert review)
72. Kabra SK, Lodha R. Antibiotics for preventing complications in children with measles. Cochrane Database Syst Rev.
2013(8):CD001477. (Systematic review)

CME Questions
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for this issue, scan the QR code below with your
smartphone or visit www.ebmedicine.net/P1216.

1. A 12-year-old boy with mumps presents with
unilateral parotid swelling and mild fever.
What can you counsel his mother concerning
mumps?
a. The patient may return to school tomorrow.
b. His household contacts are not at risk for
disease since they are vaccinated.
c. Two doses of the current vaccine are 88%
protective on average.
d. The boy cannot be reinfected with Mumps
virus.
2. A 15-month-old unvaccinated boy presents
with fever (39.5°C), cough, rhinorrhea, and red
eyes. He has white spots on his buccal mucosa.
Which of the following complications is associated with this illness?
a. Epididymo-orchitis
b. Oophoritis
c. Acute encephalitis
d. Thrombocy­topenic thrombotic purpura
3. Which of the following statements regarding
mumps is FALSE?
a. The current vaccine against mumps is 100%
protective.
b. One-third of patients with mumps are
asymptomatic.
c. Parotitis can be unilateral or bilateral.
d. Orchitis is frequently painful.
December 2016 • www.ebmedicine.net

4. Mumps virus may replicate in many internal
organs and present with which clinical presentation?
a. Mastitis
b. Congenital mumps syndrome
c. Epididymo-orchitis
d. Impetigo
5. Which of the following is the characteristic
rash associated with congenital rubella syndrome?
a. Maculopapular
b. ”Dew drop on rose petal“
c. “Blueberry muffin“ lesions
d. Urticaria
6. An 8-month-old vaccinated infant presents
with fever and a rash that started on her face
and then spread to her trunk and extremities. On examination, the rash is vesicular on
erythematous bases and is clustered into crops.
Which of the following is most likely the etiology of her infection?
a. Rubella
b. Mumps
c. Measles
d. Varicella
7. Which patient with varicella is at greatest risk
for complications and death?
a. A fetus
b. A 1-week-old infant
c. A 5-year-old girl with a history of food
allergy
d. An 11-year-old boy who was previously
vaccinated against varicella
8. This question has been removed.
9. Rubella virus can be isolated from all of the
following bodily fluids EXCEPT:
a. Seminal fluid
b. Cerebrospinal fluid
c. Urine
d. Saliva
10. Who is most at risk for severe disease from
measles, mumps, rubella, and varicella?
a. Pregnant women
b. Immunocompetent individuals
c. Adults
d. Immunized children

17 Copyright © 2016 EB Medicine. All rights reserved.

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Consider nonsur
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ED, emergency

Class Of Evidence
Each action in

department; GERD

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actions required when caring for pediatric patients

, gastroesophag

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physician

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• Safe, accepta
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• Probably useful

Practice receive

NO
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followup with primary
care
physician
• Counsel caregiv
ers on
symptoms warran
ting
return to ED

e; HPS, hypertr

Definitions

the clinical pathwa
ys section of Emerg

Class I
• Always accepta
ble, safe
• Definitely useful
• Proven in both
efficacy and effective
ness
Level of Evidenc
e:
• One or more
large prospective
studies
are present (with
rare
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consistently positive
and
compelling

for

YES

Symptoms consist

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YES

NO

ophic pyloric stenos

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is; UGI, upper

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definitions.

Class III
• May be accepta
Indeterminate
ble
• Possibly useful
• Continuing area
Level of Evidenc
of research
e:
• Considered optional
• No recommendation
• Generally higher
or alternative treats until further
levels of evidenc
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research
e
• Nonrandomized
or retrospective
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historic, cohort,
of Evidence:
or case control
Level of Evidenc
studies
e:
• Less robust random
• Generally lower
• Evidence not
ized controlled
or intermediate
available
• Results consiste
trials
levels of • Higher
evidence
ntly positive
studies in progres
s
• Case series,
• Results inconsis
animal studies,
tent, contradictory
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• Results not compell
ing
• Occasionally
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This clinical pathwa
y is intended to
supplement, rather
needs. Failure
to comply with
than substitute
this pathway does
for, professional
not represent a
Copyright © 2016
breach of the standarjudgment and may be change
EB Medicine. 1-800-2
d depending upon
d of care.
49-5770. No part
a patient’s individu
of this publication
al
may be reprodu
ced in any format
without written
consent of EB
Pediatric Pathw
Medicine.
ays:

Evidence-Based
Algorithms
ty Of Care, Vol.
II

To Improve Quali

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INTRODUCING

POINTS & PEARLS
POINTS & P
EARLS
A Quick-Read

Review Of Key

Points & Clinic

al Pearl

s, July 2016
Pediatric Severe
Traumatic Brain
Injury:
An Evidence-Ba
sed Review
Points



Cervical artery
Pearls
dissections involv
vertebral arterie
e the carotid or
s. An intimal
tear creates a
dolumen with
pseuintram
Cervical artery
later lead to vessel ural hematoma, which
dissections can
can
occlusion, throm
even
with minor traum
tion, embolus,
a or spontaneous occur
pseudoaneurysm, bus formaly.
Cervical artery
or rupture.
dissections from
Maintain a high
caused by direct
blunt trauma
index of suspic
are
blow to the neck,
artery dissections
ion of
sion or contra
hyperextenin patients presen cervical
lateral rotatio
risk
factors
ting with
n,
intrao
or
or skull-base
with any concer
ral trauma,
fractur
ning associated
finding.
occur spontaneous es. However, they can also
ly or with minor
average, sympt
trauma. On
Early administratio
oms occur 2 to
n
3 days after the
traumatic event.
of
antiplatelet
anticoagulants
significantly reduce agents or
• Cervical artery
stroke in cervica
s
dissections may
the
risk of
l artery dissec
headache, facial
present with
tions.
pain, or neck
pain and may
associated with
Cervical artery
be
neurological
dissection is not
symptoms, dysgeu
sia, pulsatile
cation for throm
a contrainditinnitu
bolytics for ischem
Risk factors includ s, or cervical radiculopath
ic stroke.
y.
vascular abnorm e connective tissue diseas
e and
• Cervical artery
• Liberal screen alities.
dissection is not
ing criteria are
for
a
contraindication
thrombolytics
recommende
High-risk findin
for ischemic stroke
d.
gs
acute strokes
. Patients with
cal deficits, Glasgo include lateralizing neurol
can receive throm
ogiw Coma Scale
bolytics safely
when cervical
cal hematoma,
score < 8, cervieven
artery dissect
bruit, thrill or
ion is
thrombolytics,
crepitus, anisoc
Horner syndro
antiplatelet agents suspected. After
oria,
me, cervical spine
tion should be
and anticoagulaFort type II or
fracture, and
Le
• Patients diagnodelayed for 24 hours.
• Though digital III fractures.
sed with a cervica
subtraction angiog
tion
l
artery
should
gold standard
dissecbe admitted and
raphy is the
for diagnosis
closely monito
Follow-up imagin
of cervical artery
sections, compu
red.
g
is
needed to assess
disted
progression in
disease
an accepted choice tomographic angiography
7 to 10 days.
is
• Due to the
and 95% to 100% , with 98% to 100% sensitivity
lack of data, blood
specificity while
pressure manag
ment targets
risks and delays
having fewer
are up
ecompared to angiog
on specific patien to individual providers based
netic resonance
raphy. Magt characteristic
angiography
s.
is also an alterna
but is not sensiti
Issue Author
tive,
ve for vertebral
• Early admin
istration of antithr artery dissection.
Rhonda Cadena
ombot
with antiplatelet
Assistant Professo , MD
agents (eg, aspirin ic therapy
r, Departments
Emergen
of
Neurolog
lants (eg, hepari
cy Medicine,
y, Neurosurgery,
University of
n) has been shown ) or anticoaguand
North Carolina,
Points & Pearls
reduce the risk
Chapel Hill, NC
Contributor
of stroke in cervica to significantly
tions. There is
l artery dissecJeremy Kim,
no clear benefi
MD
Department of
t of one agent
another, but many
Emergency Medicine
over
Sinai, New York,
prefer heparin
, Icahn School
NY
of Medicine at
an acute throm
in the setting
Mount
bus
of
contraindications or vessel occlusion. If there
are
to antithrombot
ders
ut
on
vascular treatm
sp
ic therapy, endoing abo
ent should be
First Re
are say
considered.
r peers
es Access your
July 2016 • Emerg
what you
issue by scanning
ndrom
e to
ency Medicine
Here's e:with your smartph
on Sy
practic
Practic
ati
h
my
one
e
rni
or
tablet
this issu
1
ral He
even wit
l change
Copyright © 2016
issue wil of dissections,
5. Cereb
EB
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nk All rights reserve
Fig
thine.
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always uma.
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oyed
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Excelle g them.
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section.
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I will mo tool for dis
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screen








ences

and
Refer
dence
portant
ed
et al. Inci
ion-bas
kar JN,
Mandre on: a populat ectional
ecti
RD, Jr.,
ss-s
455.71
ry diss
, Brown
12. (Cro
4486.30
Lee VH of cervical arte (10):1809-18
.000024
tment
e
6;67
/01.wnl
outcom rology. 200
telet trea artery
10.1212
ipla
I:
Neu
Ant
ical
DO
al.
study.
ents)
for cerv rol.
i C, et
48 pati
tment
E, Lev
Neu
study;
Hayter
ation trea trial. Lancet
pagul
HS,
kus
ised
anticoa
trial; 250
8. Mar pared with
a random ed controlled
DISS):
com
miz
(CA
ma
ndo
on
70018-9
67. (Ra
dissecti
422(15)
tern Trau
(4):361-3 016/S1474-4
al. Wes
EE, et
ening
n
2015;14
DOI: 10.1 CC, Moore trauma: scre ries. J
herniatio
in
falcine
tients)
1: Sub
, Cothren decisions
cular inju 097/
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vas
WL
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13. Biffl ociation crit of blunt cere view) DOI:
2: Cen
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nt
(Re
Ass
stentoria
-1153.
treatme
3: Tran
iation
nt cere
(6):1150
for and
al. Blu
sillar hern
if
2009;67 1d6
nes: the
4: Ton
LN, et
Trauma.
1c1c
section,
Diebel
t guideli Trauma.
13e318
ery dis slightly
lier BC, managemen
TA.0b0
ma. J
e
/
WJ, Col
e
vical art
mberg injury practic Surgery of TrauDOI: 10.1097
with cer sent, they havin the adult
14. Bro
the
nes)
cular
n
pre
children
tion for
brovas
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• In ptoms of are
Associa
those see ldren with
Differen
n
. (Practic
tern
al.
tha
477
et
Eas
chi
M,
sym
: the
213
(2):471- 43da
sentenant
features
ections cort of
2010;68
1cb
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mon pre
ch C, Bod
cits
different n. In a coh
13e318
Ginsba vertebral arte -1181. (Prospe /
TA.0b0
tio
most comrological defi 212
Grond1174
popula section, the
tid and
ette S,
;77(12): ents) DOI: 10.1
al neu
el of con
foc
27. Deb features of caro rology. 2011
dis
lev
re
te
pati
red
we
acu
tial
y; 982
y. Neu
).
ptoms
%), alte
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elated
CADIS
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),
822f03f ore EE, et al.
tive nes
ries: imp
:699(87.5% s (25%), and for Surger
013e31
Mo
ulation
cular injug. 2002;235(5)
nes
WNL.0b Ray CE, Jr,
iation
ic pop
brovas
ents)
Sur
a as
scious
WL,
n Assoc
pediatr
blunt cere raphy. Ann study; 171 pati
e criteri
29. Biffl
e Easter state that the
riog
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the sam
e cohort
up arte
outcom
• Th
es
using
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