Case Report

MORBILI
SKDI: 4A
ICD X: B05.9

Majdah Rummy Rosidi

Maria Aditya P Hutauruk
Nadya Rizky Oktariani

SUPERVISOR:

DR.dr.Elmi Ridar, Sp.A

PEDIATRIC DEPARTMENT OF
MEDICAL FACULTY OF RIAU UNIVERSITY
Introduction
Morbili is an infectious disease that is transmitted by individual
droplets infected with the Paramyxovirus group of measles
viruses

2016 : 12,681 cases

INDONESIA
2015: 10.655 cases

2016 : 5 out of 100,000 population

Incidence
2015: 3,2 out of 100,000 population

5-9 years old : 31,6%

Age group
1-4 years old : 25,4 %

1. Ikatan Dokter Anak Indonesia. 2010

2. Soedarmo SSP, dkk. 2012
3. Kementrian Kesehatan Republik Indonesia, 2017
Introduction
Eradication Strategies of Measles

• Measles as one of basic immunization

programs (35,2% of 12.681 cases)

Global Vaccine Action Plan

• Measles & rubella vaccine campaign (MR)

in children aged 9 months to 15 years and
introduction of MR vaccine into routine
immunization programs in October 2017
and 2018

3 Kemenkes RI. 2017

4.Kemenkes RI. 2017
Definition
Morbili is an infectious disease caused by acute viral
infection characterized by three stages such as catarral,
eruption, and convalescence stage

Etiology
Caused by Morbili Virus in Nasopharygeal and blood secretion during prodormal period up
to 24 hours after spotting

Transmission • Individual droplets

• Active at least 34 hours at room

temperature,
• 15 weeks in frozen
Viral’s
preservation,
characterize • At least 4 weeks stored at 35
°C, and several days at 0 °C. 1. Ikatan Dokter Anak Indonesia. 2010
2. Soedarmo SSP, dkk. 2012
• Virus not active at low pH.
 Pathogenesis
Virus morbili is transmitted by droplet infection

Serous exudate is formed and the

proliferation of MN and PMN cells
around the capillaries

Viruses spread to the Viruses spreads Viruses associated with

local ymphatic system hematogenously mononuclear cells

Viruses infect lymph Viruses replicate and Multinucleus giant cells are
formed and prone T
node spread into organs lymphocytes actively replicate

Focus infection was found and get into epithelial surface

of the oropharynx, conjunctiva, respiratory tract, skin etc

Clinical Manifestation

Healing Complication

1. Ikatan Dokter Anak Indonesia. 2010

2. Soedarmo SSP, dkk. 2012
Diagnosis
Physical Adjunct
Examination Examination

• Pheriperal Blood
Anamnesis Test (Limfositosis
and Leukopenia)
• Sitologic test
(Giant cell in
bucalis or
rhinose)
• Serologic test
(spesific IgM)

1. Ikatan Dokter Anak Indonesia. 2010

2. Soedarmo SSP, dkk. 2012
5. Burnside, Mcglyyn. 2014
6. Rahayu T, Tumbelaka AR. 2002
7. World Health Organization. 2008
8. American Academy of Pediatrics. 2006
9. Samuel LK. 2014
Differential Diagnosis & Treatment
Differential diagnosis
• German measles / Rubella
• Dengue Fever
• Roseola
• Scarlet fever
• Rashed mediated by toxin such as Staphylococcus scalded skin,
toxic shock syndrome, erythema multiforme, steven johnson
syndrome

Treatment

1. Ikatan Dokter Anak Indonesia. 2010

Additional 2. Soedarmo SSP, dkk. 2012

Symptomatic 7. World Health Organization. 2008

Therapy 8. American Academy of Pediatrics. 2006

9. Samuel LK. 2014
11. Maldonado. 2004
12. Judith MS. 2008
19. Humaining Y. 2005
 Prevention & Prognosis
Prevention of morbili can be through by giving the active immunization or passive
immunization
Vaccine gives subcutaneously as much as 0,5ml. The vaccine uses schwarz and
moraten strain. Measles vaccine in Indonesia is doing for children in 9 months and
18 months or MMR vaccine.

Prognosis

In children with good condition are usually bonam but malam

prognosis can be occur if general condition is bad
1. Ikatan Dokter Anak Indonesia. 2010
10. Soedarmo SSP, dkk. 2012
13. Ikatan Dokter Anak Indonesia. 2017
14. Satgas Imunisasi IDAI. 2000
15. Pusdatin Kemenkes RI. 2016
CASE REPORT
 Identity
– Name : An. MF/801580
– Address : Tangor, Pekanbaru
– Religion : Islam
– Ethnic : Minang
– Father : Mr.S
– Mother : Mrs. R
– Date of admission : June 04th 2018
– Date of examination : June 05th 2018
– Date of discharge : June 08th 2018
– Patient status : Alive
 Anamnesis
• Chief Complaint:

Fever
since 6 days before admission
Anamnesis

6 days before admission

- Sudden fever with high temperature
continiously. 3 days before admission
- Cough with white phlegm, fatigue, - Red rash started from face, continued to
decreased appetite neck, trunk, arm and feet.
- No Trembling, sweating, gum Red rash spread and thicken.
bleeding, nose bleeding, black stool,
- Red eyes, itchy.
diarhea, vomit, retroorbital pain,
abdominal pain.
Past medical • Never experienced the same disease
history before

Family medical • History of contact with neigborhood

who had the same complain 1 weeks
History ago

Pregnancy • Aterm, spontaneously, midwife,

ANC every month with midwife.
History The last of 3.
Meal history • Breast milk : 0-6 month
• Companion breast milk: 6 month – 1
(sufficient year
• Solid food : 1 year - now
nutrition)

Immunisation • Elemental immunisation not complete

history • Measles immunisation (-)

• Birth weight : 2900 gram, Birth length :

History of 48 cm
growth and • Weight now : 33 kg, Length now : 142
cm
development • Development compatible with age
 Physical Examination

General appearance : Moderate Illness

Awareness : Composmentis
Vital signs:
-Blood pressure : 120/70 mmHg
-Pulse : 116 x/min
-Respiratory rate : 25x/min
-Temperature : 37,9ºC
Nutrition : - Height : 142 cm
  - Weight : 33 kg
IBW : 36 kg
Nutritional status : (ABW / IBW) x 100%
(33 / 36) x 100% = 91,67% (normal)
 Physical Examination

Normocephal, ear and nose conjunctivitis (+/+), yellow

within normal limit. sclera (-/-),
Mouth: koplik spot (-) Light reflex (+/+), isochoric
pupil  2 mm,

Inspection: symmetrical chest

wall movement left and right,
retraction (-)
Palpation: symmetrical vocal
fremitus left and right lung
Percussion: resonant in both
lungs
Neck stiffness (-) Auscultation: Vesicular (+ / +),
Neck and axilla lymph ronkhi (-/-), wheezing (-/-)
nodes enlargement (-)

Confluent maculopapule Inspection : Ictus cordis was invisible

on face, thorac and Palpation : palpable in the left midclavicle line, ICS V
abdomen. Discrete Percussion : no cardiomegaly
maculopapule on limbs Auscultation: S1 S2 regular (+), murmur (-), gallop (-)
 Physical Examination

Inspection : Flat, scar (-),

venectation (-)
Auscultation : bowel sound (+) 8
times a minute
Palpation : supel, epigastric pain (-),
hepatomegaly (-), splenomegaly (-)
Percussion: Timpani (+), shifting
Female, normal forms, dullness (-)
congenital anomalies (-)

Warm, CRT <2 seconds,

edemam(- /-),
cyanosis (- / -)
 Workup

February 8th 2018

Blood routines:
Eosinophil: 0,1 %
Haemoglobin : 14,1 g/dl Basophil : 0,1 %
Hematocrite : 38,3 % Neutrophil: 88,7 %
Leucosit : 9.130 /ul Monocyte : 2,4 %
Platelet : 224.000 /ul Lymphocyte: 8,7 %
Eritrosite : 6.180.000
 Diagnosis

• Working diagnosis : Morbili stadium eruption

• Nutritional diagnosis : Good nutrition

 Differential diagnosis
• Rubella
• Dengue fever
• Eksantema subitum
 Therapy

Non-Pharmacology :
Isolation room.
Bed rest
Nutritional needs : 1800 kkal/day

Pharmacology :
IVFD D5 ½ NS 1760 ml/day, 18 dpm macro
Vitamin A 200.000 IU p.o. (single dose)
Ambroxol syrup 15mg/5ml 3x1cth
Paracetamol 120mg/5ml 3x3cth (fever)
 Follow Up
Day / Date Subjective Objective Assesment Therapy
Tuesday, Fever (+), General appearance Morbili eruption • IVFD D5 ½ NS 21 tpm
/6/2018 Malaise (+), : moderate illness stadium makro
cough (+), Awareness : • Paracetamol syr 3x 2 cth
composmentis prn
Blood pressure : • Ambroxol 3x1 cth
120/70 mmHg • Vitamin A 200.000 IU
Pulse : 100 x/min • Daily meal 1840
Respiratory rate : 24 kkal/day
x/min
Temperature :
37,8oC
Fotofobia (+)
Rash on the whole
body surface
Day / Date Subjective Objective Assesment Therapy
Wednesd Fever (-), General appearance : Morbili • IVFD D5 ½ NS 21 tpm
ay , Malaise (+), moderate illness eruption makro
6/6/2018 cough (+), Awareness : stadium • Paracetamol syr 3x 2 cth
composmentis prn
Blood pressure : • Ambroxol 3x1 cth
120/70 mmHg • Daily meal 1840
Pulse : 92 x/min kkal/day
Respiratory rate : 22
x/min
Temperature : 37,0 oC
Fotofobia (+)
Rash on the whole
body surface
 Day / Date Subjective Objective Assesment Therapy
Thursday, Fever (-), General appearance Morbili • IVFD D5 ½ NS 21 tpm
7/6/2018 Malaise (-), : moderate illness convalesen makro
cough Awareness : stadium • Paracetamol syr 3x 2 cth
(+)minimal composmentis prn
Blood pressure : • Ambroxol 3x1 cth
120/70 mmHg • Daily meal 1840 kkal/day
Pulse : 94 x/min
Respiratory rate : 21
x/min
Temperature : 36,8
o
C
Fotofobia (-)
Hiperpigmentation
(+)
 Day / Date Subjective Objective Assesment Therapy
Friday, Fever (-), General appearance Morbili Patient : go home
8/6/2018 Malaise (-), : moderate illness convalesen Advice : Control to Peditric
cough (-) Awareness : stadium Policlinic and to Surgeon
composmentis Doctor for UDT.
Blood pressure :
110/70 mmHg
Pulse : 94 x/min
Respiratory rate : 21
x/min
Temperature :
36,5oC
Fotofobia (-)
Hiperpigmentation
(+)
 Prognosis

• Quo ad vitam : bonam

• Quo ad functionam : bonam
Discussion
 Rubella
Differential Diagnosis Fever, malaise, anoreksia, mild
Girl, 10 year 10 month,
conjungtivits, sore throat, cough,
Complain : Red rash, demam,
limphadenopathy, maculopapular
conjungtivitis, Cough, sputum(+)
rash : appear at 1st day on face, 2nd
day spread to body and rash on
Therapy face disappear
Supportive
THEORY Vitamin A 2 x 200.000 IU
- Prodormal : fever, coriza, Cough, interval 24 hrs
conjungtivitis CASE
- Makulopapular rash D5 % ½ NS 18 dpm macro Dengue fever
- Koplik spot Vitamin A 200.000 IU p.o (single High fever, headache,
CASE dose) retroorbital pain, muscle and
- Red rash, Ambroxol syr 3 x 1 cth bone pain
- Fever, Paracetamol 3x3cth (prn) Rash disappear along with
- conjungtivitis, decreasing of temperature
- Cough with phlegm
- Measles vaccination (-)
Theory
Prodormal Stadium
Eruption Stadium Exanthema subitum
THEORY - fever, anoreksia, choriza,
Convalesense Stadium
conjungtivitis, cough
- Limfositopenia CASE - pink rash, makulopapular : 1st
- Leukopenia In : Eruption stadium day on back, face, extremities
- IgM out : convalesense stadium - Rash doesnot leave
CASE pigmentation and
- Limfositosis desquamation
- Leukosit within normal range
THANK YOU