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Hi Everyone,

I've had a bit of a hiatus from posts recently, in part waiting to change the feel of the website a bit but lagging behind on that.

However, unless you've been hibernating the past few weeks you know about the measles resurgence in the US, as well as the new measures being taken in New York City to get their outbreak under control. I've heard from many of you via phone and email, and I've suddenly become in demand by the news media, so I thought it might be helpful to share some measles information with you in a series of posts.

*Cases as of December 29, 2018. Case count is preliminary and subject to change.
**Cases as of April 4, 2019. Case count is preliminary and subject to change. Data are updated every Monday.
From https://www.cdc.gov/measles/cases-outbreaks.html

First I want to mention some basic clinical clues to help in diagnosing measles. I know that most practicing pediatricians in the US have never seen a case, and sometimes it takes an old-timer like me to help with some of the nuances. So, here goes.

At the onset, there is nothing very unique about a child with measles compared to any number of febrile children with upper respiratory infection. However, you should get in the habit now, if you aren't already, of verifying measles immunization history for every febrile patient you see, as well as asking about any known measles exposure. I've dusted off and updated my "Measles Clinical Pearls for Clinicians" to share with you:

1. Incubation Period: Onset of symptoms occurs about 10 days after exposure, but since measles patients are contagious up to 4 days prior to developing a rash, families may not report a measles exposure.
2. The Prodrome: This is the single most helpful finding in diagnosing measles, and it requires careful documentation of the history of present illness. Prodrome refers to the illness that occurs prior to development of the rash. The prodrome of measles consists of fever, malaise, cough, coryza (rhinorrhea), and conjunctivitis. None of these items distinguishes measles from several other viral illnesses, or from Kawasaki Disease. However, the duration of the prodrome can be very helpful. It would be most unusual for a child with measles to have a prodrome duration less than 2 days. So, if the history is that the child developed fever and rash on the same day, or the rash appeared the morning after fever onset the night before, you are unlikely to be dealing with measles.
3. Koplik Spots: These are likely pathognomonic of measles, but less helpful than the prodrome duration in practice because
a. They don’t appear in every measles patient
b. They often are gone by the time the rash appears, which is usually the time parents seek medical attention
c. They’re hard to see (and hard to photograph).
d. Ask for help from an experienced clinician (aka someone old enough to have seen a lot of this – once this person points out Koplik spots to you, you’ll never forget it!).
4. The Rash: Typically the rash progresses in a cephalocaudal and centrifugal fashion (top to bottom and centrally to peripherally). It’s not as helpful as you might think for diagnosis, possibly because parents might not notice this progression.
5. Diagnosis: We generally use measles IgM antibody for diagnosis. In the current outbreak, health authorities also are asking for collection of throat or NP specimens for measles PCR. You should contact your local health department for questions on collecting specimens. Of course, the ID service at Children's National is always available for help, 202-476-5051 or 202-476-4880 for page operator.
6. Treatment: Note that oral vitamin A treatment is recommended for children with severe (e.g. requiring hospitalization) measles in the US; dosage is based on age and available in the Red Book.

Measles is about the most contagious illness you’ll ever see; about 90% of non‐immune contacts will become ill. Your quick action can limit secondary cases.

Next Up: Measles vaccine: safety, efficacy, indications, and duration of immunity.

Stay tuned, and in the meantime please check out these helpful resources:
CDC Measles Page
CHOP Vaccine Education Center

Dr. Iqbal has made an excellent and timely comment to my previous post. Fortunately, the CDC has now narrowed the source of the tainted romaine to the Central Coastal regions of northern and central California. If you can determine your romaine did not come from this region, it is safe to consume. If you can't determine this, then don't eat it.

Fortunately, the lettuce harvest for this region of California has ended, so there shouldn't be any product from this area available in stores or restaurants.

Going forward, the FDA has asked lettuce growers to clearly label their bagged and packaged romaine products as to origin and harvest date, plus provide this information to retailers purchasing bulk lettuce to be sold or used in restaurants. Nonetheless, consumption of any raw food carries risks of foodborne illness. Salads, raw oysters, steak tartare all can be risky gastronomic adventures, and even cooked food carries some risk if temperatures are not properly regulated (e.g. the big tub of potato salad at a picnic) or if a typhoid Mary happens to prepare your food, as occurred in a fast-food restaurant in downtown Silver Spring in 1986.

You and your patients' families might be interested in the CDC's Food Safety website.

This afternoon I received an alert from the CDC regarding shiga-toxin producing E. coli likely linked to romaine lettuce. The specific source of the tainted lettuce still isn't clear, which has led CDC to make the unusual recommendation for consumers to throw out all romaine lettuce they may have.

So far, a total of 50 individuals are known to have been infected in the outbreak, spread across the US (32 cases) and Canada (18). One case of hemolytic-uremic syndrome has occurred, but no fatalities known so far.

As you can see above, we've had a single case in Maryland. I don't know any details about that individual case.

Although the warning is all over the news, please warn the families in your practice to get rid of any romaine in the house, and clean any areas that were in contact with the lettuce. You can view the complete alert for more details which include 5 steps on how to clean the refrigerator.

I'll bet most every pediatrician has seen the media blitz regarding AFM cases. I've been a little disappointed in most coverage by the lay press; they seem to be making this out to be more mysterious than it really is. (I did see one instance of well-balanced coverage in the Atlantic online, which included a quote from my colleague (and boss!) at Children's National, Roberta DeBiasi.)

Here's the scoop without the hype. Shortly after AFM became better recognized in 2014, CDC developed case definitions that were updated in 2017. The case definitions differ depending on whether one is considering reporting a new case or ultimately classifying a case as Probable of Confirmed AFM. Regardless, three criteria are used. First is the presence of acute onset of flaccid limb weakness, i.e. characterized by diminished or absent deep tendon reflexes. The second characteristic is MRI evidence of a spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments. Lastly, the third feature is evidence of CSF pleocytosis (WBC > 5/cubic mm). A confirmed case consists of the first 2 elements, regardless of CSF findings. Upticks in AFM seem to be occurring in even-numbered years: 2014, 2916, and now 2018. Here is the CDC's current (as of October 31) graph of cases:

I guess the mysterious part of all this, as seen by the lay press, is that no one entity has been shown to be the cause of AFM. However, healthcare providers shouldn't be mystified; we know that many different (and common) viruses can cause encephalitis and myelitis. Also, the same virus infecting one individual might cause only mild upper respiratory symptoms or even no symptoms at all, while the same viral strain could cause AFM in a neighbor. Polio is the classic example of this: 95% of wild polio infections are asymptomatic, and the majority of the rest produce only mild symptoms or aseptic meningitis with no sequelae. Paralytic polio represents the tip of the iceberg, no more than 1-2% of all infections. The role of age seems to be different for AFM, where paralytic disease is seen primarily in children, compared to polio which, although causing paralysis in all age groups is more severe in older individuals.

So far, two different enteroviruses, D68 and 71, have been associated in different years with some but by no means all of the cases. It seems likely that AFM is a syndrome that can be triggered by multiple infectious entities.

The role of primary care pediatricians in AFM management is 2-fold. First, PCPs can help explain AFM to worried patients and families. To that end, the CDC has some excellent resources. Second, PCPs should consider AFM in a child presenting with any type of weakness. Weakness, particularly if associated with diminished deep tendon reflexes, should prompt referral for subspecialty care.

Note that AFM is a reportable disease. Generally, this reporting will be the responsibility of the clinician diagnosing the condition, in this case usually at a referral center. Reporting procedures vary by jurisdiction of the patient's residence. DC, Virginia, and Maryland have information and reporting resources available.