Figure 1

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Case history

A 21-year-old primigravida female presented to the hospital in preterm labor, with an otherwise uneventful pregnancy except for a febrile illness after exposure to family members with measles a week prior.

She reported having fever, cough, conjunctivitis, and a rash that started on her face and spread to her trunk, consistent with measles. Her fever and symptoms had mostly resolved, except for her lingering rash that began 6days earlier. In the delivery room, she still had fresh excoriation marks on her arms. She had not received any MMR (mumps, measles, rubella) vaccines.

Six hours after admission, the patient delivered a female infant via spontaneous vaginal delivery at 35 weeks’ gestation. The baby weighed 2410 grams, which was approximately the 50^th percentile for her gestational age. The baby had mild respiratory distress after delivery and briefly required supplemental oxygen via blow by during transitioning. Apgar’s of 8 at 1 minute and 9 at 5 minutes was given at delivery. The baby subsequently improved and was allowed to room in with mother without the need for NICU admission. The nursing staff noticed a rash on the baby’s back.

Prenatal labs

Lab tests came back negative for group B streptococcus and was nonimmune for rubella. Maternal sexually transmitted disease (STD) labs were negative, and all other prenatal labs were unremarkable. The measles reverse transcriptase polymerase chain reaction (RT-PCR) test came back positive in both mother and baby.

Newborn physical exam

The baby’s general physical examination was normal except for mild respiratory distress that subsequently resolved within two hours. Other pertinent physical findings:

• Neurological: The baby was sleepy but arousable with slightly decreased tone and reflexes consistent with preterm gestational age.
• Lungs: Clear on auscultation with intermittent tachypnea without significant respiratory distress.
• Skin: Maculopapular erythematous exanthem scattered over baby's back and trunk consistent with measles (Figure 1).

Diagnosis

• Preterm infant of 35 completed weeks of gestation
• Congenital Measles without complication
• Transient Neonatal Hypoglycemia
• Transient tachypnea of the newborn

Hospital course

Although the mother was beyond the four-day infectious period for measles and was no longer infectious, both she and her baby were placed in airborne isolation with contact precautions in a negative pressure room, due to the risk of congenital measles, pending the results of viral studies. An infectious disease specialist was consulted, and baby was started on empiric measles treatment with immune globulin intramuscular (IGIM) and vitamin A, pending results of measles investigations. The hospital did not have the capability to perform measles testing, so the sample was sent to the state lab for confirmation. An oropharyngeal sample was submitted for Measles RT-PCR testing, which later returned positive.

The baby did not have significant respiratory distress or require supplemental oxygen, and her tachypnea progressively improved over four hours. The baby was afebrile but subsequently developed hypothermia and was transferred to a NICU airborne isolation room. The baby had

feeding difficulties initially, but her feeding progressively improved within the first 2 days of admission. She also had transient hypoglycemia and had to be given glucose gel.

All the baby’s symptoms could be explained by her prematurity except for the rash observed on the back, which improved during hospital stay and was gone by day three when she was discharged home. The mother declined routine erythromycin, hepatitis B vaccine, and vitamin K despite counseling on the risks and benefits.

Results of initial laboratory evaluations are summarized in the accompanying Table 1.

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Discussion

This case brings awareness of an uncommon presentation of measles in the newborn, as well as awareness about the dangers of vaccine refusal. Amid the recent measles outbreak in West Texas, the mother in this case was from a community susceptible to measles due to common vaccine refusal.¹This case could have been prevented by routine childhood immunization for measles. 

The management of Measles is aimed at prevention via routine immunization according to the American Academy of Pediatrics (AAP) immunization schedule. However, the MMR vaccines cannot be given in pregnancy because of the theoretical risk of causing harm to the fetus when the mother receives a live virus vaccine.²

Since the introduction of the measles vaccination program, the number of measles cases decreased significantly during the late 1960s, and early 1970s. One dose of measles-containing vaccine administered at age ≥12 months was approximately 94% effective in preventing measles (range: 39%–98%). ² Figure 2 shows this decline in the number of measles cases in the United States from 1961 through 2025 after the introduction of the 1-dose measles vaccination program.² Endemic measles was declared eradicated from the United States in 2000.⁴

However, since 2020, due to increased incidence of vaccine refusal, there has been a resurgence in measles reports in the United Sates. According to the CDC, “during 2020–2023, 241 measles cases were reported in the United States, and the median number of measles cases reported per year was 53 (range: 13 to 121 cases/year).”³

Figure 2. Number of Measles Cases—United States, 1961–2025

Diagnosis of measles

The diagnosis of measles is based on clinical examination, history, and confirmatory testing. The confirmatory testing of patients suspected with measles should ideally include both serologic testing and specific detection of measles viral RNA by nucleic acid amplification test (NAAT) such as the RT-PCR. Diagnosis can also be confirmed by a fourfold increase in measles immunoglobulin G (IgG) anti-body in two specimens collected at least 10 days apart; or by isolation of the measles virus in cell culture.²

Following measles virus infection in an unvaccinated individual, measles immunoglobulin M (IgM) antibodies appear within the first few days (1 to 4 days) of rash onset and peak within the first week after rash onset. IgM testing is most sensitive ≥3 days after rash onset and may be detectable for up to 6 to 8 weeks after rash onset.³

The diagnosis of congenital measles through viral RNA testing is typically not available in most hospitals. Treatment was initiated for the baby based on the maternal history and her presentation with a morbilliform rash, to prevent measles complications while awaiting the final lab results.

The Measles real time, RT-PCR test is reliable and has a sensitivity and specificity greater than 90%.² A positive result indicates the presence of measles virus. Specific viral detection with rRT-PCR can also mitigate the impact of early false negative IgM in infants.³

Treatment

There are currently no specific anti-viral treatments developed for measles. Measles virus is susceptible in vitro to ribavirin, which has been administered by the intravenous and aerosol routes to treat severely affected and immunocompromised children with measles.⁵

Vitamin A: The World Health Organization (WHO) recommends vitamin A for all children with measles, because it has been shown to decrease morbidity and mortality.⁶ Vitamin A for treatment of measles is administered once daily for 2 days. This regimen was given to our baby without any obvious adverse effects.

Vaccination: Measles containing vaccine should be considered in all exposed individuals who are eligible. Evidence suggests that if the vaccine is given within 72 hours of measles exposure to susceptible individuals, it will provide protection or disease modification in some cases.⁵

The postexposure prophylaxis for measles can be administered according to the guidelines outlined in the Redbook and the recommendations of the Centers for Disease Control and Prevention (CDC) adult schedule in Table 2.⁵

Adapted from a table developed by New York City Department of Health: www1.nyc.gov/assets/doh/downloads/pdf/imm/pep-measles-providers.pdf.Additional source: Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013. MMWR Recomm Rep. 2013;62(RR-4):1-34; and Gastanaduy P, Redd S, Clemmons N, et al. Chapter 7: Measles. In: Roush SW, Baldy LM, Kirkconnell Hall MA, eds. Manual for the Surveillance of Vaccine-Preventable Diseases. Centers for Disease Control and Prevention. Page last reviewed May 13, 2019. Available at: www.cdc.gov/vaccines/pubs/s0urv-manual/chpt07-measles.html

a Acceptable evidence of immunity includes written documentation of age-appropriate vaccination, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957.

bMMR vaccine is not indicated in this age group.

c Dosing of IGIM is 0.5 mL/kg of body weight (max dose 15 mL).

dThe quarantine period is 21 days after the last exposure; most health departments would extend the monitoring period to 28 days if IG is administered as PEP, because IG can prolong the incubation period. Decisions on whether exposed persons who received IG as PEP appropriately (ie, within 6-day window) should return to settings such as child care, school, or work (ie, not be quarantined) should include consideration of the immune status and intensity of contacts in the setting and presence of high-risk individuals. These persons should be excluded from health care settings.

e Quarantine is not needed for persons who received MMR as PEP appropriately (ie, within the 3-day window), although these persons should be excluded from health care settings for 21 days.

f IGIM is recommended for infants <12 months of age, and IG administered intravenously is recommended for nonimmune pregnant people and severely immunocompromised persons. IGIM can be given to other persons (eg, ≥12 months of age) who do not have evidence of measles immunity, but priority should be given to persons exposed in settings with intense, prolonged, close contact (eg, household, child care, classroom).

Immune Globulin for Prevention of Measles

Human immune globulin (IG), a blood product prepared from the plasma of thousands of donors, provides antibodies for short-term prevention of infectious diseases such as measles. Persons who have measles disease typically have higher measles antibody titers than persons who have vaccine-induced measles immunity.⁷ Immune globulin preparations can be administered intramuscularly (IGIM), intravenously (IGIV), or subcutaneously (IGSC).

Historically, IGIM has been the preferred choice for short-term measles prophylaxis and has demonstrated proven efficacy for measles postexposure prophylaxis.⁸ The recommended dose of IGIM is 0.5mL/kg. IGIM has been used as prophylaxis to prevent or lessen the severity of measles and was shown to reduce the risk for measles if administered within 6 days of exposure.⁷

Measles Susceptibility in Babies

Babies are usually protected from measles at birth by passively acquired maternal antibodies. The extent of this protection depends largely on the amount of antibody transferred, which is related to gestational age and maternal antibody titer.⁹

However, mothers with vaccine-derived measles immunity typically have lower antibody titers and provide shorter protection to their baby compared with mothers with immunity derived from direct measles infection.⁹ Thus, infants born now are more susceptible to measles at a younger age. Seroepidemiologic studies already indicate that 7% of infants born in the United States may lack anti-measles antibodies at birth and up to 90% of infants might be seronegative by 6 months.² These findings suggest a change in the window of vulnerability for measles infection during infancy, and a strong need to preserve herd protection and access to immunoglobulin products when postexposure prophylaxis is needed.²

Infection Prevention

In addition to standard precautions, airborne transmission precautions are indicated for 4 days after the onset of rash in otherwise healthy children and for the duration of illness in immunocompromised patients^{. 5}

Outbreak Control

Every suspected measles case should be reported immediately to the state and local health department, who can help with active surveillance for additional cases to prevent the spread of infection. Every effort must be made to obtain laboratory evidence that would confirm that the illness is measles and to provide postexposure prophylaxis if recommended.⁵

Differential diagnosis¹⁰

There aren’t many conditions that would present like our index patient with generalized truncal maculopapular rashes at birth. However, several benign vesiculopustular eruptions appear in the newborn period. The differential diagnosis of generalized vesiculopustular newborn eruptions is listed below.

• Erythema toxicum

This common newborn skin lesion usually presents with multiple erythematous macules and papules that rapidly progress to pustules on an erythematous base. The lesions are not usually present at birth and typically occur on the second or third day of life and resolve within a week.

• Transient neonatal pustular melanosis

This skin may occur at birth as small non-erythematous pustules, present on the trunk and neck. The pustules do not have any surrounding erythema and eventually rupture into brown-black hyperpigmented macules with a surrounding collarette of scale that resolves within a few weeks. They are typically scattered on the face and sacrum are not usually generalized to the trunk.

• Miliaria

This is a transient vesiculopapular skin lesion seen in newborns. The lesions are papular with minimal erythema. They are caused by the accumulation of sweat in obstructed sweat ducts. It is common in warm climates. It usually occurs after a few days and is not seen at birth.

Infectious Vesiculopustular Eruptions

Several viral and bacterial infections can present with a skin lesion in the neonatal period. Most viral exanthems in the newborn are vesiculopustular and not maculopapular and are often localized. Lesions are rarely seen at birth and occur after a few days or weeks. Herpes simplex virus (HSV) and varicella-zoster virus (VZV) are the two most common viral infections, but the skin lesions caused by these viruses eventually become bullous and vesicular. There would be a preceding history of maternal viral infection.

• Congenital rubella

The skin lesions of rubella are typically papules and purpuric. They have been described as blueberry muffins because of the purpuric lesions. Our patient did not have any other symptoms suggestive of congenital rubella such as hearing loss or cataracts.

• Congenital syphilis

The skin lesions are small reddish-copper maculopapular eruptions. They could also present as hemorrhagic vesicles or bullae and petechiae that start on the palms and soles and spread to the trunk. if present at birth congenital syphilis would also present with other symptoms such as nasal secretions and bone abnormalities.

• Congenital cutaneous candidiasis

This may present within 12 hours of birth. The lesions are small, diffuse, erythematous macules and pustules, often involving the palms and soles. There would be a preceding history of maternal infection.

• Cutaneous streptococcal infection

Skin manifestation of streptococcus is uncommon in the newborn period. Group A streptococcus may cause an erysipelas-like eruption. Skin lesions would typically be localized vesiculopustular, abscesses, or cellulitis.

• Congenital scabies

This is rare in developed countries but may present within a few weeks with itchy skin that often affects the extremities. Lesions are localized initially but may spread to the trunk.

• Staphylococcal pustulosis

The skin lesions typically occur after a few days and are rarely seen at birth. This presents with localized, superficial, vesicular, pustular, or bullous lesions on an erythematous base. Lesions are usually found in areas of trauma, such as the diaper area, axillae, and periumbilical skin. Lesions rupture into superficial erosions and honey-colored crusts.

References:

1. Devi Shastri, Amanda Seitz. A Texas child who was not vaccinated has died of measles, a first for the US in a decade. apnews.com. updated February 26, 2025. Accessed February 26, 2025. https://apnews.com/article/measles-outbreak-west-texas-death-rfk-41adc66641e4a56ce2b2677480031ab9?utm_source=copy&utm_medium=share
2. Huong Q. McLean, PhD et al. Morbidity and Mortality Weekly Report (MMWR), Recommendations and Reports, "Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary of Recommendations of the Advisory Committee on Immunization Practices (ACIP)." http://www.cdc.gov/mmwr. Updated June 14, 2013. Accessed February 26, 2025. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm
3. Thomas D. Filardo, et al. Chapter 7: Measles. CDC Manual for the Surveillance of Vaccine-Preventable Diseases. cdc.gov. Updated May 13, 2019. Accessed February 26, 2025. https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-7-measles.html
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6. Hayley Gans, MD, Yvonne A Maldonado, MD. Measles: Clinical manifestations, diagnosis, treatment, and prevention. In: Connor R, ed. UpToDate. Wolters Kluwer; 2024. Updated January 15, 2025. Accessed February 27, 2025. https://www.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-prevention
7. Audet S, Virata-Theimer ML, Beeler JA, et al. Measles-virus-neutralizing antibodies in intravenous immunoglobulins. J Infect Dis 2006;194:781-9.
8. Janeway CA. Use of concentrated human serum γ-globulin in the prevention and attenuation of measles. Bull N Y Acad Med 1945;21:202-22.
9. Lennon JL, Black FL. Maternally derived measles immunity in era of vaccine-protected mothers. J Pediatr 1986;108:671–6.