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Measles (rubeola) is a highly infectious disease caused by a paramyxovirus of worldwide distribution. Humans are the principal reservoirs of measles virus, which is spread by respiratory droplet aerosols produced by sneezing and coughing. Vaccines have dramatically reduced the incidence of indigenous measles in the United States and have eliminated the disease altogether in some developed countries. In undernourished children in developing countries, measles can cause a devastating illness, and case-fatality rates may reach or exceed 25%.6 Before widespread vaccine use, epidemics occurred every 2 to 3 years in developed countries, and the illness developed in 95% of urban dwellers before they reached 15 years of age.
The portals of entry for measles virus include cells of the respiratory tract and possibly the conjunctivae. Approximately 9 to 11 days after a person is initially exposed to the virus, malaise, fever, conjunctivitis, photophobia, perior-bital edema, coryza, and cough develop.
A severe atypical presentation of measles may appear in persons who were immunized between 1963 and 1967 with killed measles virus vaccine and who were later exposed to the wild virus. In an epidemic setting, observation of the characteristic rash, fever, coryza, and conjunctivitis is sufficient to establish the diagnosis. Sporadic cases of measles must be differentiated from other viral exanthems, secondary syphilis, scarlet fever, and drug reactions. Measles virus infection often involves the central nervous system, but clinically apparent encephalomyelitis is rare (one in every 1,000 to 2,000 measles patients). In vaccination guidelines in the United States, two immunizations are suggested for children before school enrollment to reduce the chance of primary vaccine failure. Figure 1 A case of measles in a young man is characterized by maculopapular rash and conjunctivitis. Mumps virus is a pleomorphic, enveloped, single-stranded RNA paramyxovirus capable of causing parotitis, epididymo-orchitis, and CNS disease.
Mumps virus has worldwide distribution, and infection is seen more commonly in winter and spring. A live mumps virus vaccine was approved for use in the United States in 1967; its use was facilitated by subsequent incorporation with measles and rubella (MMR) vaccine.
Mumps virus spreads from person to person by direct contact with nasopharyngeal secretions. Two thirds of cases are symptomatic, with initial symptoms of malaise and fever predominating. An unvaccinated child who presents with tender parotitis generally has mumps; further diagnostic testing is not required. Definitive diagnosis of mumps can be made by virus isolation from the oropharynx, CSF, or urine or by virus serology.
Epididymo-orchitis occurs in up to 38% of postpubertal males with mumps and is usually unilateral. CSF pleocytosis occurs in at least 50% of patients with mumps,20 although symptomatic meningitis is less common. Treatment of patients with mumps is largely supportive, although anti-inflammatory agents may be useful in cases of severe orchitis or arthritis.
Rubella, or German measles, is usually a benign febrile exan-them, but when it occurs in pregnant women, it can produce major congenital malformations. Humans are the only known natural hosts for the rubella virus, which appears to be spread by respiratory droplets.
After an incubation period of 12 to 23 days, a mild prodrome of malaise, headache, fever, and mild conjunctivitis may develop.
The presence of rubella can be confirmed by virus isolation, by PCR detection, or by demonstration of seroconversion in response to rubella antigens. The most common complications of rubella are arthropathies of the fingers, wrists, and knees; they occur predominantly in young women. Congenital rubella syndrome, also a rare complication of acute rubella, may manifest itself as defects in one or many organ systems.
Pregnant women infected with rubella virus who are asymptomatic may still transmit rubella to their fetuses. Because they fear possible complications from MMR vaccination, some parents question the safety of the vaccine, and in some cases, they are refusing its use in their children.
In addition, although receipt of the MMR vaccine has been associated with an increased risk of febrile seizures 8 to 14 days after vaccination, those children were not found to be at higher risk for subsequent seizures or neurodevelopmental disabilities.
Although only recently recognized as a human pathogen, parvovirus B19 is now appreciated as a cause of several syndromes in both children and adults. What infections cause pinkeye, what are infectious pinkeye symptoms, and how are they treated? What noninfectious conditions cause pinkeye, what are noninfectious pinkeye symptoms, and how are they treated? Next: What infections cause pinkeye, what are infectious pinkeye symptoms, and how are they treated? Other common causes of red eye include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis.A thorough patient history and eye examination may provide clues to the etiology of red eye (Figure 1). Viral conjunctivitis usually spreads through direct contact with contaminated fingers, medical instruments, swimming pool water, or personal items. The measles virus was once one of the most common and important global pathogens, but infections caused by this agent are now becoming rare in developed countries, where vaccine use is widespread. The disease may be contagious from several days before the onset of rash to up to 5 days after lesions appear.


After undergoing local replication and spreading to regional lymph nodes, measles virus is disseminated to distant sites, particularly skin and mucous membranes, by a leukocyte-associated viremia. After a prodrome of fever, headache, abdominal pain, and myalgias, a rash develops on the hands and feet and advances toward the head. Complications occur more commonly in adults, malnourished children, and immunocompromised patients. CNS involvement may precede the rash but usually begins 4 to 7 days after the eruption appears. Other measles complications include thrombocytopenia with associated purpura or bleeding, myocarditis, pericarditis, hepatitis, and severe keratitis progressing to blindness.
Vaccination is recommended for nonpregnant women of childbearing years and may be considered for institutionalized adults or individuals working in day care centers [see CE:V Adult Preventive Health Care]. Because of widespread vaccination efforts, its role as a major cause of childhood morbidity has greatly diminished. In older age groups, other entities (sarcoidosis, tumors, alcohol abuse, drug side effects, and other viral or bacterial infections) should be considered.
A lymphocyt-ic pleocytosis is seen, with an elevated protein level and a normal to low (10%) glucose level. After the virus invades the bloodstream, it may spread to the skin and distal organs or, transplacentally, to the developing fetus.
Damage to the fetus is most likely to occur if the mother is infected within the first 2 months of gestation (fetal abnormalities are observed in 40% to 85% of such cases).27,28 Infection within the third month is associated with fetal defects in 20% to 40% of cases, whereas infection during the fourth month is associated with fetal defects in 10% of cases.
Postauricular, suboccipital, and posterior cervical lymphade-nopathy often precede the rash, which begins on the face and forehead. Virus isolation is often difficult because rubella virus does not cause cytopathic effects on the cell lines that are generally employed in diagnostic laboratories. Such arthropathies consist of arthralgia or frank arthritis, and recurring joint symptoms may persist for a year or more.
Hearing impairment is the most common single defect (60%).25 Heart malformations, particularly patent ductus arteriosus and peripheral pulmonic stenosis, are also common (45%), as are cataracts (25%), microcephaly (27%), and mental retardation (13%).
Thus, testing of immune status is advisable for women of childbearing age and for hospital employees who have no history of rubella vaccination.
These parents may cite research suggesting that MMR vaccination may be a risk factor for inflammatory bowel disease31 and autism.32 Subsequent research, however, has not supported this hypothesis. Parvovirus B19, a small (20 to 26 nm), single-stranded DNA virus, causes erythema infectio-sum (fifth disease) in normal persons, aplastic crises in persons with underlying hemolytic disorders, chronic anemia in im-munocompromised hosts, and fetal loss in pregnant women. The history should include questions about unilateral or bilateral eye involvement, duration of symptoms, type and amount of discharge, visual changes, severity of pain, photophobia, previous treatments, presence of allergies or systemic disease, and the use of contact lenses.
The attack rate for exposed susceptible contacts may exceed 90%; asymptomatic infections are rare. In 1989, the World Health Assembly instituted major efforts to reduce measles morbidity and mortality through implementation of control strategies. Lesions on mucous membranes (Koplik spots) appear as bluish-white specks on an erythematous base.
Within 2 to 3 days, Koplik spots may appear on the buccal mucosa and occasionally on the conjunctivae.
The eruption may be vesicular, urticarial, mac-ulopapular, or hemorrhagic and is most prominent along body creases. Multinucleated giant cells can often be detected in stained smears of nasal secretions, and measles antigen can be demonstrated in such cells by immuno-fluorescence.
The onset of encephalomyelitis is often precipitous and is characterized by a rise in fever, sudden mental deterioration, and seizures; motor defects and cerebellar ataxia are common. Severely immunocompromised individuals should avoid measles vaccination because of the risk of vaccine-associated diseases, such as inclusion body encephalitis or pneumonitis. Infection is uncommon in persons younger than 1 year, and congenital infection is rare but can lead to fetal loss in the first trimester.
Symptomatic encephalitis occurs in one of 6,000 cases and presents as decreased consciousness and focal neurologic deficits.
Prevention can be achieved in well over 90% of persons by the use of live attenuated mumps vaccine, administered twice as part of the recommended MMR vaccine regimen15 [see CE:VAdult Preventive Health Care].
Before the introduction of a rubella vaccine, in 1969, epidemics occurred in the United States at 6- to 9-year intervals, predominantly in children younger than 15 years.
The virus may be present in throat washings or blood for several days before the appearance of the rash and up to 2 weeks after its onset.
Mechanisms of fetal damage are not clear but may include viral cytolysis, chromosomal breaks, reduced cell multiplication, and alteration of fetal blood supply.
Within 1 to 5 days, the discrete maculopapular lesions spread over the trunk and extremities and may coalesce. Antibodies are often present shortly after rash appears and increase in titer during the next 2 to 3 weeks.
Malformation of bone metaphyses may also be present, together with hepatosplenomegaly, thrombocytopenia, interstitial pneumonitis, myocarditis, and thrombocytopenic purpura. About 10% to 15% of such persons are seronegative and should be vaccinated when not pregnant.
There he was involved in research in radiation biology and received the Huisking Scholarship. Other common causes include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis. The eye examination should include the eyelids, lacrimal sac, pupil size and reaction to light, corneal involvement, and the pattern and location of hyperemia.


The clinical presentation of viral conjunctivitis is usually mild with spontaneous remission after one to two weeks.3 Treatment is supportive and may include cold compresses, ocular decongestants, and artificial tears. By 1996, estimated incidence and death rates were reduced by 78% and 88%, respectively.1,7,8 In the Americas, between 1990 and 1996, the number of new measles cases decreased from 246,607 to 2,109 (a decrease of 99%), and vaccine coverage increased from 77% to 85%. Histologically, Koplik spots are composed of epithelioid giant cells with cytoplasmic and nuclear inclusions that contain microtubular aggregates; inflammatory cells and in tercellular edema are present.
The skin rash, which erupts 2 to 3 days later, usually appears at the hairline and spreads downward during the next 3 days as systemic symptoms subside [see Figure 1]. The virus can be isolated from nasal secretions or urine by cultivation of such materials on primate cell monolay-ers.
An autoimmune demyelinating process may be involved in the pathogenesis of measles encephalomyelitis, which is fatal in about 10% of patients. Approximately 11% of cases of mumps are observed in children between 1 and 4 years of age, 52% in children between 5 and 14 years of age, and 11% in children older than 15 years. Since the widespread use of rubella vaccine, the incidence of rubella has decreased by 99%.25 Outbreaks continue to occur, primarily in young adults in hospitals, colleges, prisons, and prenatal clinics, but no major epidemics have occurred in the United States since 1964. In rare cases of rubella arthropathy, the virus may persist in peripheral leukocytes or in synovial cells for months to years. As a result, fetal growth may be retarded, and defects may develop in multiple organ systems.
Encephalitis occurs in one in 6,000 cases,15 and thrombocytopenia, which is sometimes associated with pur-pura or hemorrhage, occurs most often in children.
Congenitally infected infants are often of low birth weight (23%), and they excrete rubella virus for prolonged periods. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents, as well as to underlying diseases within the body. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina.
Signs and symptoms of red eye include eye discharge, redness, pain, photophobia, itching, and visual changes.
Lesions of the skin also demonstrate inclusions and microtubular aggregates, suggesting that active viral replication occurs in skin as well as in mucous membranes. All persons vaccinated after 1967 received the live attenuated measles vaccine, which is rarely, if ever, associated with the atypical measles syndrome.
A rise in hemagglutination inhibition antibodies during a period of 2 to 3 weeks confirms the diagnosis. Both humoral and cell-mediated immune responses are induced and correlate with cessation of viremia and salivary virus excretion. Despite the production of fetal antibodies, the rubella virus can persist in the fetus and newborn and can be excreted for months to years after birth.
Late complications may result from imbalances of cellular and humoral immunity, from immune complex deposition, or from prolonged viral replication. Viral and bacterial forms of conjunctivitis are common in childhood, but they occur in adults as well. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. Generally, viral and bacterial conjunctivitis are self-limiting conditions, and serious complications are rare.
Infectious virus can be isolated from leukocytes, urine, conjunctivae, and respiratory secretions. Diabetes mellitus and other endocrine abnormalities may be late complications of congenital rubella, as is subacute sclerosing panencephalitis. Because there is no specific diagnostic test to differentiate viral from bacterial conjunctivitis, most cases are treated using broad-spectrum antibiotics. Patients need prompt ophthalmology referral for aggressive management.4,12 Acute bacterial conjunctivitis is the most common form of bacterial conjunctivitis in the primary care setting. Complete recovery without scarring generally occurs within 7 to 10 days from the onset of the rash. The cause of red eye can be diagnosed through a detailed patient history and careful eye examination, and treatment is based on the underlying etiology.
Recognizing the need for emergent referral to an ophthalmologist is key in the primary care management of red eye. Staphylococcus aureus infection often causes acute bacterial conjunctivitis in adults, whereas Streptococcus pneumoniae and Haemophilus influenzae infections are more common causes in children. Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Although chloramphenicol is the first-line treatment in other countries, it is no longer available in the United States. Polymerase chain reaction testing of conjunctival scrapings is diagnostic, but is not usually needed.
Seasonal allergic conjunctivitis is the most common form of the condition, and symptoms are related to season-specific aeroallergens. Allergic conjunctivitis is primarily a clinical diagnosis.Avoiding exposure to allergens and using artificial tears are effective methods to alleviate symptoms.



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