Measles differential diagnosis

Jump to navigation Jump to search

Measles Microchapters


Patient Information


Historical Perspective



Differentiating Measles from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis


Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Chest X Ray

Other Diagnostic Studies


Medical Therapy

Primary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Measles differential diagnosis On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides


American Roentgen Ray Society Images of Measles differential diagnosis

All Images
Echo & Ultrasound
CT Images

Ongoing Trials at Clinical

US National Guidelines Clearinghouse

NICE Guidance

FDA on Measles differential diagnosis

CDC on Measles differential diagnosis

Measles differential diagnosis in the news

Blogs on Measles differential diagnosis

Directions to Hospitals Treating Measles

Risk calculators and risk factors for Measles differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]; Vidit Bhargava, M.B.B.S [3]


Measles is a disease characterized by the classical clinical triad of cough, coryza and conjunctivitis. In most cases the presentation is classical and the diagnosis can be sufficiently made clinically. However, in a few cases certain other diagnostic possibilities must be kept in mind. These include other viral exanthams such as erythema infectiosum, other maculopapular rashes etc. Also, in areas where killed vaccines are used, the probability of atypical measles with fever, conjunctivitis, pneumonitis and rash must be kept in mind. It is worthwhile to consider Kawasaki's disease, rubella, dengue, systemic lupus erythematosus and serum sickness while considering the diagnosis of measles.

Differentiating Measles from other Diseases

The following table summarizes the most commonly confused conditions with measles:

Differential Diagnosis of Measles. Table adapted from CDC Pinkbook.[1]
Disease Agent Typical Season Typical Age Prodrome Fever Duration of the rash (days) Rash Other Signs & Symptoms
Measles Paramyxovirus
Measles virus
Winter - Spring 1 to 20 years 2-4 days of cough, conjunctivitis, and coryza High 5 - 6 Erythematous, irregular size, maculopapular; starts on temples and behind ears; progresses down from face; fades to brownish Koplik's spots: C blue-white papules (salt grains) on bright red mucosa opposite premolar teeth
Kawasaki disease Unknown Winter - Spring < 5 years 3 days of abrupt fever High; fever of 5 days is a diagnostic criteria 5 - 7 Erythematous, morbilliform, maculopapular or scarlatiniform, central distribution; erythematous, indurated palms and soles Acute: dry, fissured and injected lips, strawberry tongue; irritability; cervical lymphadenopathy; conjunctival injection; peripheral edema; Subacute: finger-tip desquamation; Complications: arthritis, carditis
Roseola Infantum (exanthem subitum) Human herpes virus type 6 Any season 6 months to 2 years None High 1-2; it follows defervescence Discrete erythematous macules, rarely involves face, begins as fever ends Lymphadenopathy, irritability
Rubella Togavirus Spring 7 months to 29 years 0 - 4 days; mild malaise, fever; absent in children Low grade 1 - 3 Discrete, rose-pink, diffuse, maculopapular; progresses downward from face, may change quickly Arthralgia (usually in adults), tender posterior cervical and suboccipital lymphadenopathy, malaise, petechiae on soft palate
Scarlet Fever ß-hemolytic streptococci Winter > 2 years 0 - 6 day, marked Low to high 2 - 7 Scarlet "sunburn" with punctate papules "sandpaper", circumoral pallor, increased intensity in skin folds, blanches stars face/head, upper trunk and progresses downward Sore throat, exudative tonsillitis, vomiting, abdominal pain, lmphadenopathy, white then red strawberry tongue
Erythema Infectiosum (Fifth Disease) Human parvovirus type B19 Spring 5 - 10 years None, usually in children, may occur in adults None to low-grade 2 - 4 Starts as “slapped cheek”, maculopapular; progresses to reticular (lacy) pattern; can recur with environmental changes such as sunlight exposure Arthralgia/arthritis in adults, adenopathy
Enterovirus Echovirus
Coxsackie virus
Summer - Fall Mainly childhood 0 - 1 day fever and myalias Low to high 1 - 5 Fine, pink, always affects face; variant is Boston exanthem (large ~ 1 cm, discrete maculopapules) Sore throat, headache, malaise, no lymphadenopathy, gastroenteritis
Dengue Fever Flavivirus
Dengue virus types 1 - 4
None High 1 - 5 Generalized maculopapular rash after defervescence; spares palms and soles Headache, myalgia, abdominal pain, pharyngitis, vomiting
Drug induced rash Many Any Any Possible due to underlying illness Possible Varies Typically diffuse but may be concentrated in diaper area, typically no progression, erythema multiform rash can progress over a few days Possibly due to underlying illness or complications
Infectious Mononucleosis Epstein-Barr Virus None 10 - 30 years 2 - 5 days of malaise and fatigue Low to high 2 - 7 Trunk and proximal extremities. Rash common if Ampicillin given Pharyngitis, lymphadenopathy, splenomegaly, malaise
Pharyngoconjunctival Fever Adenovirus types 2, 3, 4, 7, 7a Winter - Spring < 5 years Low to high 3 - 5 Starts on face and spreads down to trunk and extremities Sore throat, conjunctivitis, headache, anorexia

The following table is a list of differential diagnosis oral lesions presenting similar to measles:

Disease Presentation Risk Factors Diagnosis Affected Organ Systems Important features Picture
Coxsackie virus
  • Symptomatic treatment
Hand-foot-and-mouth disease
Chicken pox Chickenpox
Measles Koplick spots (Measles)
  • Attendance at a kindergarten/child care center
  • Contact with herpangina cases
  • Residence in rural areas
  • Overcrowding
  • Poor hygiene
  • Low socioeconomic status
  • Skin
  • Oral Cavity
  • Characteristic enanthem- Punctate macule which evolve over a period of 24 hours to 2-4mm erythematous papules which vesiculate, and then centrally ulcerate.
  • The lesions are usually small in number, and evolve rapidly. The lesions are seen more commonly on the soft palate and uvula. The lesions can also be seen on the tonsils, posterior pharyngeal wall and the buccal mucosa.
Erythema, vesicles and ulcerating lesions in herpangina
Erythema, vesicles and ulcerating lesions in herpangina
Primary herpetic gingivoestomatitis[4]
  • Oral cavity
  • Mucous membranes
  • Ulcers are common on lips, gums, throat, front of tongue, inside of the cheeks and roof of the mouth
  • Treatment is with antiviral agents such as Valacyclovir and Famciclovir

Koplik spots must be differentiated from other diseases causing oral lesions such as leukoplakia and herpes simplex virus infection.

Disease Presentation Risk Factors Diagnosis Affected Organ Systems Important features Picture
Diseases predominantly affecting the oral cavity
Oral Candidiasis
  • Denture users
  • As a side effect of medication, most commonly having taken antibiotics. Inhaled corticosteroids for the treatment of lung conditions (e.g, asthma or COPD) may also result in oral candidiasis which may be reduced by regularly rinsing the mouth with water after taking the medication.
  • Clinical diagnosis
  • Confirmatory tests rarely needed
Localized candidiasis

Invasive candidasis

Tongue infected with oral candidiasis - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg
Herpes simplex oral lesions
  • Stress
  • Recent URTI
  • Female sex
  • The symptoms of primary HSV infection generally resolve within two weeks
Oral herpes simplex infection - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=19051042.jpg
Aphthous ulcers
  • Painful, red spot or bump that develops into an open ulcer
  • Physical examination
  • Diagnosis of exclusion
  • Oral cavity
  • Self-limiting , Pain decreases in 7 to 10 days, with complete healing in 1 to 3 weeks
Apthous ulcer on the lower surface of the tongue - By Ebarruda - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=7903358
Squamous cell carcinoma
Squamous cell carcinoma - By Luca Pastore, Maria Luisa Fiorella, Raffaele Fiorella, Lorenzo Lo Muzio -, CC BY 2.5,
  • Vulvar lesions occur independent of oral lesions
Leukoplakia - By Aitor III - Own work, Public Domain,
Oral melanoma - By Emmanouil K Symvoulakis, Dionysios E Kyrmizakis, Emmanouil I Drivas, Anastassios V Koutsopoulos, Stylianos G Malandrakis, Charalambos E Skoulakis and John G Bizakis - Symvoulakis et al. Head & Face Medicine 2006 2:7 doi:10.1186/1746-160X-2-7 (Open Access), [1], CC BY-SA 2.0,
Fordyce spots
Fordyce spots - Por Perene - Obra do próprio, CC BY-SA 3.0,
Burning mouth syndrome
Torus palatinus
Torus palatinus - By Photo taken by dozenist, CC BY-SA 3.0,
Diseases involving oral cavity and other organ systems
Behcet's disease
Behcet's disease - By Ahmet Altiner MD, Rajni Mandal MD -, CC BY-SA 3.0,
Crohn's disease
oral syphilis - By CDC/Susan Lindsley -, Public Domain,
Coxsackie virus
  • Symptomatic treatment
Coxsackie virus stomatitis - Adapted from Dermatology Atlas.[9]
Chicken pox
Chickenpox - By James Heilman, MD - Own work, CC BY-SA 4.0,
  • Unvaccinated individuals[2][3]
  • Crowded and/or unsanitary conditions
  • Traveling to less developed and developing countries
  • Immunocompromized
  • Winter and spring seasons
  • Born after 1956 and never fully vaccinated
  • Health care workers
Koplick spots (Measles) - By CDC -, Public Domain,


  1. "Epidemiology and Prevention of Vaccine-Preventable Diseases".
  2. 2.0 2.1 Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE (2000). "Individual and community risks of measles and pertussis associated with personal exemptions to immunization". JAMA. 284 (24): 3145–50. PMID 11135778.
  3. 3.0 3.1 Ratnam S, West R, Gadag V, Williams B, Oates E (1996). "Immunity against measles in school-aged children: implications for measles revaccination strategies". Can J Public Health. 87 (6): 407–10. PMID 9009400.
  4. Kolokotronis, A.; Doumas, S. (2006). "Herpes simplex virus infection, with particular reference to the progression and complications of primary herpetic gingivostomatitis". Clinical Microbiology and Infection. 12 (3): 202–211. doi:10.1111/j.1469-0691.2005.01336.x. ISSN 1198-743X.
  5. Chauvin PJ, Ajar AH (2002). "Acute herpetic gingivostomatitis in adults: a review of 13 cases, including diagnosis and management". J Can Dent Assoc. 68 (4): 247–51. PMID 12626280.
  6. Ann M. Gillenwater, Nadarajah Vigneswaran, Hanadi Fatani, Pierre Saintigny & Adel K. El-Naggar (2013). "Proliferative verrucous leukoplakia (PVL): a review of an elusive pathologic entity!". Advances in anatomic pathology. 20 (6): 416–423. doi:10.1097/PAP.0b013e3182a92df1. PMID 24113312. Unknown parameter |month= ignored (help)
  7. Andrès E, Zimmer J, Affenberger S, Federici L, Alt M, Maloisel F. (2006). "Idiosyncratic drug-induced agranulocytosis: Update of an old disorder". Eur J Intern Med. 17 (8): 529–35. Text "pmid 17142169" ignored (help)
  8. title="By Internet Archive Book Images [No restrictions], via Wikimedia Commons" href=""
  9. "Dermatology Atlas".

Template:WikiDoc Sources