Measles differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]Vidit Bhargava, M.B.B.S [3]
Overview
Measles is a disease characterized by the classical clinical triad of cough, coryza and conjunctivitis. In most cases the presentation is classical and the diagnosis can be sufficiently made clinically. However, in a few cases certain other diagnostic possibilities must be kept in mind. These include other viral exanthams such as erythema infectiosum, other maculopapular rashes etc. Also, in areas where killed vaccines are used, the probability of atypical measles with fever, conjunctivitis, pneumonitis and rash must be kept in mind. It is worthwhile to consider Kawasaki's disease, rubella, dengue, systemic lupus erythematosus and serum sickness while considering the diagnosis of measles.
Differentiating Measles from other Diseases
The following table summarizes the most commonly confused conditions with measles:
| Disease | Agent | Typical Season | Typical Age | Prodrome | Fever | Duration of the rash (days) | Rash | Other Signs & Symptoms |
|---|---|---|---|---|---|---|---|---|
| Measles | Paramyxovirus Measles virus |
Winter - Spring | 1 to 20 years | 2-4 days of cough, conjunctivitis, and coryza | High | 5 - 6 | Erythematous, irregular size, maculopapular; starts on temples and behind ears; progresses down from face; fades to brownish | Koplik's spots: C blue-white papules (salt grains) on bright red mucosa opposite premolar teeth |
| Kawasaki disease | Unknown | Winter - Spring | < 5 years | 3 days of abrupt fever | High; fever of 5 days is a diagnostic criteria | 5 - 7 | Erythematous, morbilliform, maculopapular or scarlatiniform, central distribution; erythematous, indurated palms and soles | Acute: dry, fissured and injected lips, strawberry tongue; irritability; cervical lymphadenopathy; conjunctival injection; peripheral edema; Subacute: finger-tip desquamation; Complications: arthritis, carditis |
| Roseola Infantum (exanthem subitum) | Human herpes virus type 6 | Any season | 6 months to 2 years | None | High | 1-2; it follows defervescence | Discrete erythematous macules, rarely involves face, begins as fever ends | Lymphadenopathy, irritability |
| Rubella | Togavirus | Spring | 7 months to 29 years | 0 - 4 days; mild malaise, fever; absent in children | Low grade | 1 - 3 | Discrete, rose-pink, diffuse, maculopapular; progresses downward from face, may change quickly | Arthralgia (usually in adults), tender posterior cervical and suboccipital lymphadenopathy, malaise, petechiae on soft palate |
| Scarlet Fever | ß-hemolytic streptococci | Winter | > 2 years | 0 - 6 day, marked | Low to high | 2 - 7 | Scarlet "sunburn" with punctate papules "sandpaper", circumoral pallor, increased intensity in skin folds, blanches stars face/head, upper trunk and progresses downward | Sore throat, exudative tonsillitis, vomiting, abdominal pain, lmphadenopathy, white then red strawberry tongue |
| Erythema Infectiosum (Fifth Disease) | Human parvovirus type B19 | Spring | 5 - 10 years | None, usually in children, may occur in adults | None to low-grade | 2 - 4 | Starts as “slapped cheek”, maculopapular; progresses to reticular (lacy) pattern; can recur with environmental changes such as sunlight exposure | Arthralgia/arthritis in adults, adenopathy |
| Enterovirus | Echovirus Coxsackie virus |
Summer - Fall | Mainly childhood | 0 - 1 day fever and myalias | Low to high | 1 - 5 | Fine, pink, always affects face; variant is Boston exanthem (large ~ 1 cm, discrete maculopapules) | Sore throat, headache, malaise, no lymphadenopathy, gastroenteritis |
| Dengue Fever | Flavivirus Dengue virus types 1 - 4 |
None | High | 1 - 5 | Generalized maculopapular rash after defervescence; spares palms and soles | Headache, myalgia, abdominal pain, pharyngitis, vomiting | ||
| Drug induced rash | Many | Any | Any | Possible due to underlying illness | Possible | Varies | Typically diffuse but may be concentrated in diaper area, typically no progression, erythema multiform rash can progress over a few days | Possibly due to underlying illness or complications |
| Infectious Mononucleosis | Epstein-Barr Virus | None | 10 - 30 years | 2 - 5 days of malaise and fatigue | Low to high | 2 - 7 | Trunk and proximal extremities. Rash common if Ampicillin given | Pharyngitis, lymphadenopathy, splenomegaly, malaise |
| Pharyngoconjunctival Fever | Adenovirus types 2, 3, 4, 7, 7a | Winter - Spring | < 5 years | Low to high | 3 - 5 | Starts on face and spreads down to trunk and extremities | Sore throat, conjunctivitis, headache, anorexia |
Other diseases to be considered:
- Meningococcal meningitis presenting with spots on lower back and chest
- Roseola infantum
- Rocky Mountain Spotted Fever
- Toxic Shock Syndrome