With outbreaks of measles occurring across the country, the largest in Texas with 279 cases including 36 hospitalizations and one death as of March 18, 2025, measles is on everyone’s minds. Over the next few days, we’ll cover what you need to know about measles, starting with clinical suspicion, diagnosis, and management.
Clinical Suspicion of Measles
Measles often starts off like any other viral respiratory infection, commonly with fever and cough. However, the virus can also affect mucosal tissues of the eyes, nose, and mouth resulting in conjunctivitis, coryza, and buccal Koplik spots. Physicians should pay close attention to mucosal signs in patients presenting with upper respiratory symptoms, especially those practicing in outbreak areas. Notably, Koplik spots, which are often tiny white or blue-gray specks on an erythematous palate, are pathognomonic for measles, meaning the clinical diagnosis of measles is met when this sign is present.
Koplik Spots - Koplik spots on palate on day 3 of the illness in the pre-eruptive phase of measles. Image courtesy of Centers for Disease Control and Prevention/Heinz F. Eichenwald. Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention. This material is otherwise available on the CDC website for no charge.
About two-to-four days after the onset of fever, a red, maculopapular rash begins on the face and head, often along the hairline, and proceeds to spread downward to the trunk and extremities. The rash may become confluent, particularly on the upper body, and desquamation may occur in severely affected areas. Lesions initially blanch with pressure but no longer do so after about three days, so the timing of evaluation matters when palpating the skin. The rash typically resolves after five-to-six days in the same order it appeared (facial lesions disappearing first, followed by trunk and extremities).
Measles: Typical maculopapular rash of measles gradually spreads from head to neck to trunk to limbs. Copyright© 2014, EBSCO Information Services.
Diagnosis of Measles
A diagnosis of measles can be made clinically, and all suspected cases should be reported to state or local health departments (the U.S. directory of local health departments can be found at National Association of County & Health Officials [NACCHO]). The local health department will coordinate confirmatory testing to be performed at the Centers for Disease Control and Prevention (CDC) Measles Virus Laboratory. The most common test to confirm a measles diagnosis is serum antibody testing to detect measles-specific IgM and/or IgG, though reverse transcriptase-PCR to identify the virus from throat, nasal, or nasopharyngeal swab, urine, blood, or oral fluid may also be used.
Management of Measles
Without specific antiviral therapy available, the care of patients with measles is entirely supportive.
Outpatient management is similar to that of other upper respiratory diseases and may include antipyretics, nasal irrigation, and use of cough and cold products (in adults). Vitamin A supplementation may be considered because it’s been shown to reduce morbidity, and in some situations mortality (specifically in hospitalized, malnourished children in resource limited settings). Vitamin A is provided in two doses given 24 hours apart and dosing varies by age (50,000 units/dose for children under 6 months, 100,000 units/dose for children aged 6-11 months, and 200,000 units/dose for children over one year).
Antibiotics should be reserved for patients with bacterial coinfection such as pneumonia or otitis media. About 20 percent of patients require hospitalization, most commonly due to the development of pneumonia. Mortality varies widely depending on age, nutritional status, immunocompromise, vaccination, and healthcare access.
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Stay tuned for the next article in this series Measles Outbreaks in the United States: Vaccination Recommendations in Routine Practice and Outbreak Settings and subscribe below to get the next article delivered to your inbox.
