Measles pneumonia in young adults. An analysis of 106 cases

Measles: An Overview of a Re-Emerging Disease in Children and Immunocompromised Patients

Despite the availability of a safe and effective vaccine, in 2018, around 350,000 measles cases were reported worldwide, which resulted in an estimate of 142,300 deaths from measles. Additionally, in 2017, global measles cases spiked, causing the death of 110,000 people, mostly children under the age of 5 years and immunocompromised adults. The increase in measles incidence is caused by the ongoing reduction of vaccination coverage. This event has triggered public and scientific interest. For this reason, we reviewed the pathophysiology of measles infection, focusing on mechanisms by which the virus spreads systemically through the host organism. By reaching the lymphocytes from the airways through a "trojan horse" strategy, measles induces an immunosuppression status. H and F glycoproteins, both expressed in the envelope, ensure attachment of the virus to host cells and spreading from one cell to another by binding to several receptors, as described in detail. The severity of the disease depends both on the age and underlying conditions of patients as well as the social and health context in which epidemics spread, and is often burdened by sequelae and complications that may occur several years after infection. Particular attention was paid to special groups that are more susceptible to severe or atypical measles. An overview of microbiology, symptoms, diagnosis, prevention, and treatment completes and enriches the review.

Measles-associated pneumonia and hepatitis during the measles outbreak of 2018

Background Between 2017 and 2018, Greece experienced a measles outbreak, affecting >3000 patients, most of which were unvaccinated. Measles-associated pneumonia (MAP) is the most common serious compilation of the disease, but very few recent reports regarding its presentation are available. Materials and Methods Between January and May 2018, 11 adult patients presented to our department with acute measles virus infection, hypoxia and findings on chest X-ray. Clinical, laboratory and radiological data were collected and assessed. Nine out of eleven patients had hypoxic respiratory failure. Other complications included hepatitis, cholestasis and myositis, which were observed in the majority of patients. All patients received supplementary oxygen administration, whereas five patients required continuous positive airway pressure ventilation. Scoring of the radiological examinations performed was most notable for the presence of reticular opacities and consolidations. Statistical analysis demonstrated a significant association between PaO2/FiO2 values and the presence of reticular opacities, with PaO2/FiO2 decreasing as the mean value of the reticular opacities score increased (P = .02). Conclusion To our knowledge, this is the first report demonstrating an association between PaO2/FiO2 values and the presence of reticular opacities in patients with MAP. MAP should be suspected in any patient presenting with acute onset hypoxaemia and a reticular pattern on radiological examination, especially in outbreak settings. What is known Measles infections are on the rise in Europe, with epidemics affecting several European countries, resulting from suboptimal immunisation. The most common serious complication of measles is pneumonia, which is more common in adult patients and can cause significant morbidity. It is the most common cause of death due to measles. What is new In this report, we present 11 adults with measles-associated pneumonia, who presented with the combination of acute measles virus infection, hypoxia and findings on chest X-ray. To our knowledge, this is the first report demonstrating an association between the severity of hypoxaemia and the presence of reticular opacities on chest imaging studies.

Infectious Lung Disease

Infectious diseases are one of the main causes of morbidity and mortality worldwide. With new pathogens continuously emerging, known infectious diseases reemerging, increasing microbial resistance to antimicrobial agents, global environmental change, ease of world travel, and an increasing immunosuppressed population, recognition of infectious diseases plays an ever-important role in surgical pathology. This becomes particularly significant in cases where infectious disease is not suspected clinically and the initial diagnostic workup fails to include samples for culture. As such, it is not uncommon that a lung biopsy becomes the only material available in the diagnostic process of an infectious disease. Once the infectious nature of the pathological process is established, careful search for the causative agent is advised. This can often be achieved by examination of the hematoxylin and eosin-stained sections alone as many organisms or their cytopathic effects are visible on routine staining. However, ancillary studies such as histochemical stains, immunohistochemistry, in situ hybridization, or molecular techniques may be needed to identify the organism in tissue sections or for further characterization, such as speciation.

Pulmonary measles disease: old and new imaging tools

BACKGROUND

Measles virus can cause lower respiratory tract infection, so that chest radiography is necessary to investigate lung involvement in patients with respiratory distress.

PURPOSE

To assess measles pneumonia imaging during the measles outbreak occurred in 2016-2017 in Italy.

MATERIAL AND METHODS

We retrospectively observed adult patients with a serological diagnosis of measles, who underwent chest-X rays for suspected pneumonia. If a normal radiography resulted, the patient underwent unenhanced CT. A CT post processing software package was used for an additional quantitative lung and airway involvement analysis .

RESULTS

Among 290 patients affected by measles, 150 underwent chest-X ray. Traditional imaging allowed the pneumonia diagnosis in 114 patients (76%). The most frequent abnormality at chest X-rays was bronchial wall thickening, observed in 88.5% of the cases; radiological findings are faint in the 25% of the cases (29/114 patients). In nine subjects with a normal chest X-ray, unenhanced CT with a quantitative analysis was performed, and depicted features consistent with constrictive bronchiolitis.

CONCLUSION

Measles may produce bronchiolitis and pneumonia. In the cases in which involvement of pulmonary parenchyma is not sufficient to result in radiological abnormalities, CT used with a dedicated postprocessing software package, provides an accurate lungs and airways analysis, also determining the percentage of lung involvement.

How to hold an ethical pox party

Pox parties are a controversial alternative to vaccination for diseases such as chickenpox. Such parties involve parents infecting non-immune children by exposing them to a contagious child. If successful, infection will usually lead to immunity, thus preventing infection later in life, which, for several vaccine-preventable diseases, is more severe than childhood infection. Some may consider pox parties more morally objectionable than opting out of vaccination through non-medical exemptions. In this paper, I argue that this is not the case. Pox parties involve immediate risk of harm for children and reduce future harms, whereas opting out of vaccination places children at long-term risk of harms that increase with time, at least for some pathogens. Regarding harm to others through onward transmission of infection, this can be easily prevented in the case of pox parties-given the relatively controlled timing of infection-by quarantining attendees after the party, whereas opting out of vaccination involves risks to others that are more difficult to control. I defend three criteria for an ethical pox party: (1) that the disease is sufficiently low risk, (2) that parents consent to their child's attendance and (3) that children exposed to infection are quarantined and isolated appropriately. I argue that, if these criteria are met, pox parties are morally preferable to non-vaccination; such parties involve less risk to non-consenting others and, for some pathogens in some cases, even involve less risk for the children who participate. Thus, policies that permit non-medical exemption to vaccination should also permit ethical pox parties. Alternatively, if pox parties are not permitted, then vaccination should be mandated for those without medical contraindication.

Perspective on Global Measles Epidemiology and Control and the Role of Novel Vaccination Strategies

Measles is a highly contagious, vaccine preventable disease. Measles results in a systemic illness which causes profound immunosuppression often leading to severe complications. In 2010, the World Health Assembly declared that measles can and should be eradicated. Measles has been eliminated in the Region of the Americas, and the remaining five regions of the World Health Organization (WHO) have adopted measles elimination goals. Significant progress has been made through increased global coverage of first and second doses of measles-containing vaccine, leading to a decrease in global incidence of measles, and through improved case based surveillance supported by the WHO Global Measles and Rubella Laboratory Network. Improved vaccine delivery methods will likely play an important role in achieving measles elimination goals as these delivery methods circumvent many of the logistic issues associated with subcutaneous injection. This review highlights the status of global measles epidemiology, novel measles vaccination strategies, and describes the pathway toward measles elimination.

Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications

Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.

The Association between Invasive Group A Streptococcal Diseases and Viral Respiratory Tract Infections

Viral infections of the upper respiratory tract are associated with a variety of invasive diseases caused by Streptococcus pyogenes, the group A streptococcus, including pneumonia, necrotizing fasciitis, toxic shock syndrome, and bacteremia. While these polymicrobial infections, or superinfections, are complex, progress has been made in understanding the molecular basis of disease. Areas of investigation have included the characterization of virus-induced changes in innate immunity, differences in bacterial adherence and internalization following viral infection, and the efficacy of vaccines in mitigating the morbidity and mortality of superinfections. Here, we briefly summarize viral-S. pyogenes superinfections with an emphasis on those affiliated with influenza viruses.

Kingella kingae: carriage, transmission, and disease

Kingella kingae is a common etiology of pediatric bacteremia and the leading agent of osteomyelitis and septic arthritis in children aged 6 to 36 months. This Gram-negative bacterium is carried asymptomatically in the oropharynx and disseminates by close interpersonal contact. The colonized epithelium is the source of bloodstream invasion and dissemination to distant sites, and certain clones show significant association with bacteremia, osteoarthritis, or endocarditis. Kingella kingae produces an RTX (repeat-in-toxin) toxin with broad-spectrum cytotoxicity that probably facilitates mucosal colonization and persistence of the organism in the bloodstream and deep body tissues. With the exception of patients with endocardial involvement, children with K. kingae diseases often show only mild symptoms and signs, necessitating clinical acumen. The isolation of K. kingae on routine solid media is suboptimal, and detection of the bacterium is significantly improved by inoculating exudates into blood culture bottles and the use of PCR-based assays. The organism is generally susceptible to antibiotics that are administered to young patients with joint and bone infections. β-Lactamase production is clonal, and the local prevalence of β-lactamase-producing strains is variable. If adequately and promptly treated, invasive K. kingae infections with no endocardial involvement usually run a benign clinical course.

Diagnosis of Measles Pneumonia from Bronchoalveolar Lavage Fluid by Reverse-Transcriptase Polymerase Chain Reaction: Case Report

A 24-year-old male contracted measles during treatment with prednisolone for bronchial asthma and eosinophilic pneumonia. Five days after the appearance of skin eruptions, infiltration shadows were detected in the hilum of the left lung on a chest X-ray and a chest computed tomography revealed diffuse macular and infiltration shadows in both lungs and in the left S6 segment, respectively. Pneumonia complicating measles may be caused by either the measles virus itself or by a secondary bacterial infection. Since this patient had been treated with prednisolone, pneumonia caused by a pathogen other than bacteria, or recurrence of eosinophilic pneumonia were suspected, and bronchoalveolar lavage was performed. Culture of the bronchoalveolar lavage fluid (BALF) was negative for bacteria, acid-fast bacilli, and mycetes, and polymerase chain reaction (PCR) analysis did not detect cytomegalovirus, but reverse transcriptase PCR did detect the measles virus. There were increased lymphocytes in the BALF with a significantly reduced CD4/CD8 ratio. Histological findings revealed alveolitis. Based on conventional diagnostic criteria, pneumonia due to the measles virus was confirmed. Since the criteria of pneumonia due to measles virus includes histological, serological and bacteriological studies which require an extended period of time, RT-PCR using BALF may be useful for the rapid diagnosis of measles pneumonia.

Maternal, fetal, and neonatal outcomes associated with measles during pregnancy: Namibia, 2009-2010

BACKGROUND

Previous studies of maternal, fetal, and neonatal complications of measles during pregnancy suggest the possibility of increased risk for morbidity and mortality. In 2009-2011, a nationwide laboratory-confirmed measles outbreak occurred in Namibia, with 38% of reported cases among adults. This outbreak provided an opportunity to describe clinical features of measles in pregnant women and assess the relative risk for adverse maternal, fetal, and neonatal outcomes.

METHODS

A cohort of pregnant women with clinical measles was identified retrospectively from 6 district hospitals and clinics over a 12-month period. Each pregnant woman with measles was matched with 3 pregnant women without measles, randomly selected from antenatal clinic registers at the same hospital during the same time interval. We reviewed hospital and clinic records and conducted in-person interviews to collect demographic and clinical information on the pregnant women and their infants.

RESULTS

Of 55 pregnant women with measles, 53 (96%) were hospitalized; measles-related complications included diarrhea (60%), pneumonia (40%), and encephalitis (5%). Among pregnant women with known human immunodeficiency virus (HIV) status, 15% of those without measles and 19% of those with measles were HIV positive. Of 42 measles-related pregnancies with known outcomes, 25 (60%) had ≥1 adverse maternal, fetal, or neonatal outcome and 5 women (12%) died. Compared with 172 pregnancies without measles, after adjusting for age, pregnancies with measles carried significantly increased risks for neonatal low birth weight (adjusted relative risk [aRR] = 3.5; 95% confidence interval [CI], 1.5-8.2), spontaneous abortion (aRR = 5.9; 95% CI, 1.8-19.7), intrauterine fetal death (aRR = 9.0; 95% CI, 1.2-65.5), and maternal death (aRR = 9.6; 95% CI, 1.3-70.0).

CONCLUSIONS

Our findings suggest that measles virus infection during pregnancy confers a high risk of adverse maternal, fetal, and neonatal outcomes, including maternal death. Maximizing measles immunity among women of childbearing age would decrease the incidence of gestational measles and the attendant maternal, fetal, and neonatal morbidity and mortality.

Severe Measles Infection: The Spectrum of Disease in 36 Critically Ill Adult Patients

France has recently witnessed a nationwide outbreak of measles. Data on severe forms of measles in adults are lacking. We sought to describe the epidemiologic, clinical, treatment, and prognostic aspects of the disease in adult patients who required admission to an intensive care unit (ICU). We performed a retrospective analysis of a cohort of 36 adults admitted to a total of 64 ICUs throughout France for complications of measles from January 1, 2009, to December 31, 2011. All cases of measles were confirmed by serologic testing and/or reverse transcription polymerase chain reaction.The cohort consisted of 21 male and 15 female patients, with a median age of 29.2 years (25th-75th interquartile range [IQR], 27.2-34.2 yr) and a median Simplified Acute Physiology Score (SAPS II) of 13 (IQR, 9-18). Among the 26 patients whose measles vaccination status was documented, none had received 2 injections. One patient had developed measles during childhood. Underlying comorbid conditions included chronic respiratory disease in 9 patients, immunosuppression in 7 patients, and obesity in 3 patients, while measles affected 5 pregnant women.Respiratory complications induced by measles infection led to ICU admission in 32 cases, and measles-related neurologic complications led to ICU admission in 2 cases. Two patients were admitted due to concurrent respiratory and neurologic complications.Bacterial superinfection of measles-related airway infection was suspected in 28 patients and was documented in 8. Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS). Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases. Five patients died, all of whom were severely immunocompromised.On follow-up, 1 patient had severe chronic respiratory failure related to lung fibrosis, and 2 patients had mild lower limb paraparesis along with bladder dysfunction, both of which were ascribable to measles-induced encephalitis and myelitis. Among the 5 pregnant patients, the course of measles infection was uneventful, albeit 1 patient underwent emergent cesarean delivery because of fetal growth restriction.Measles is a disease with protean and potentially deceptive clinical manifestations, especially in the immunocompromised patient. Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality. In contrast with the usually benign course of the disease in immunocompetent patients, measles occurring in immunocompromised patients gives rise to lethal complications including ARDS, with or without bacterial superinfection. Other patients potentially at high risk for severe measles are young adults and pregnant women. Measles pneumonitis may predispose to air leak disease in patients using mechanical ventilation. To date, vaccination remains the most potent tool to control measles infection.

Antibiotics for preventing complications in children with measles

BACKGROUND

Measles is the leading killer among vaccine-preventable diseases; it is responsible for an estimated 44% of the 1.7 million vaccine-preventable deaths among children annually.

OBJECTIVES

To assess the effects of antibiotics given to children with measles to prevent complications and reduce pneumonia, other morbidities and mortality.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (1966 to May week 4, 2013) and EMBASE (1980 to May 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing antibiotics with placebo or no treatment, to prevent complications in children with measles.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

Seven trials with 1263 children were included. The methodological quality of most studies was poor. Only two studies were randomized, double-blind trials. There was variation in antibiotics used, their doses, schedule and evaluation of outcome. Pooled study data showed that the incidence of pneumonia was lower in the treatment group compared to the control group. However, the difference was not statistically significant. Of the 654 children who received antibiotics, 27 (4.1%) developed pneumonia; while out of 609 children in the control group, 59 (9.6%) developed pneumonia (odds ratio (OR) 0.35; 95% confidence interval (0.12 to 1.01). The one trial that showed an increase in the rate of pneumonia with antibiotics was conducted in 1942 and compared oral sulfathiazole with symptomatic treatment. If the results of this trial are removed from the meta-analysis, there is a statistically significant reduction in the incidence of pneumonia in children receiving antibiotics (OR 0.26; 95% CI 0.12 to 0.60). The incidence of other complications was significantly lower in children receiving antibiotics: purulent otitis media (OR 0.34; 95% CI 0.16 to 0.73) and tonsillitis (OR 0.08; 95% CI 0.01 to 0.72). There was no difference in the incidence of conjunctivitis (OR 0.39; 95% CI 0.15 to 1.0), diarrhea (OR 0.53; 95% CI 0.23 to 1.22) or croup (OR 0.16; 95% CI 0.01 to 4.06). No major adverse effects attributable to antibiotics were reported.

AUTHORS' CONCLUSIONS

The studies reviewed were of poor quality and used older antibiotics. This review suggests a beneficial effect of antibiotics in preventing complications such as pneumonia, purulent otitis media and tonsillitis in children with measles. On the basis of this review, it is not possible to recommend definitive guidelines on the type of antibiotic, duration or the day of initiation. There is a need for more evidence from high-quality RCTs to answer these questions.

[The role of atypical microorganisms and viruses in severe acute community-acquired pneumonia]

Usually, intensivists do not focus on atypical bacteria and viruses in severe community-acquired pneumonia (CAP). Only Legionella pneumophila and influenza virus, following the recent H1N1 influenza pandemic, are routinely suggested as responsible agents. However, CAP due to atypical bacteria may represent up to 44% of all CAP. Viral CAP is considered less severe than the usual bacterial ones, although 25% of them warrant hospitalization and 15% result in severe sepsis. Even though L. pneumophila is the most frequently atypical pathogen involved in severe cases, Mycoplasma pneumoniae may be responsible for multiorgan failure. To date, tools including detection of Legionella antigen in urine and Mycoplasma using polymerase chain reaction (PCR) allow rapid and accurate diagnosis. The treatment is based on macrolides and fluoroquinolones that can be associated in severe Legionnaire diseases. The presence of virus in CAP, either alone or in association with bacteria, has been demonstrated using molecular biology tests. These techniques also allowed the identification of several new viruses in CAP. However, the exact role of these detected viruses in CAP as well as the efficiency of antiviral therapy still represent major unsolved concerns.

Measles virus and associated central nervous system sequelae

Worldwide, measles remains one of the most deadly vaccine-preventable diseases. In the United States, enrollment in the public schools requires that each child receives 2 doses of measles-containing vaccine before entry, essentially eliminating this once endemic disease. Recent outbreaks of measles in the United States have been associated with importation of measles virus from other countries and subsequent transmission to intentionally undervaccinated children. The central nervous system complications of measles can occur within days or years of acute infection and are often severe. These include primary measles encephalitis, acute postinfectious measles encephalomyelitis, measles inclusion body encephalitis, and subacute sclerosing panencephalitis. These measles-associated central nervous system diseases differ in their pathogenesis and pathologic effects. However, all involve complex brain-virus-immune system interactions, and all can lead to severe and permanent brain injury. Despite better understanding of the clinical presentations and pathogenesis of these illnesses, effective treatments remain elusive.

Viruses associated with pneumonia in adults

Viral pneumonia, which is typically associated with disease in childhood, is increasingly recognized as causing problems in adults. Certain viruses, such as influenza virus, can attack fully immunocompetent adults, but many viruses take advantage of more-vulnerable patients. The latter include patients receiving immunosuppressive therapy and elderly subjects, particularly those residing in long-term care facilities. The range of viruses producing pneumonia in adults includes common agents, such as varicella-zoster virus and influenza virus, as well as respiratory syncytial virus, human metapneumovirus, adenoviruses, picornaviruses, and coronaviruses. The roles played by other agents, such as rhinoviruses and human bocaviruses, in pneumonia are still under study. While therapy for most of theses agents, at least in adults, has not yet been fully clarified, it is reasonable to assume antivirals may work in certain situations if they are introduced early enough in the course of infection.

Measles: old vaccines, new vaccines

Isolation of measles virus in tissue culture by Enders and colleagues in the 1960s led to the development of the first measles vaccines. An inactivated vaccine provided only short-term protection and induced poor T cell responses and antibody that did not undergo affinity maturation. The response to this vaccine primed for atypical measles, a more severe form of measles, and was withdrawn. A live attenuated virus vaccine has been highly successful in protection from measles and in elimination of endemic measles virus transmission with the use of two doses. This vaccine is administered by injection between 9 and 15 months of age. Measles control would be facilitated if infants could be immunized at a younger age, if the vaccine were thermostable, and if delivery did not require a needle and syringe. To these ends, new vaccines are under development using macaques as an animal model and various combinations of the H, F, and N viral proteins. Promising studies have been reported using DNA vaccines, subunit vaccines, and virus-vectored vaccines.

Antibiotics for preventing complications in children with measles

BACKGROUND

Measles is the leading killer among vaccine-preventable diseases, responsible for an estimated 44% of the 1.7 million vaccine-preventable deaths among children annually.

OBJECTIVES

To assess the effects of antibiotics given to children with measles to prevent complications and reduce pneumonia, other morbidities and mortality.

SEARCH STRATEGY

In this 2008 update we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1) MEDLINE (1966 to January week 1, 2008), EMBASE (1980 to December 2007) and the National Research Register (Issue 3, 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing antibiotics with placebo or no treatment to prevent complications in children with measles.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

Seven trials with 1385 children were included. Pooled study data showed that the incidence of pneumonia was lower in the treatment group compared to the control group. However, the difference was not statistically significant. In children who received antibiotics, 1.9% developed pneumonia, while in the control group 6% developed pneumonia (OR 0.28; 95% CI 0.06 to 1.25). The one trial that showed an increase in the rate of pneumonia with antibiotics was conducted in 1942 and compared oral sulfathiazole with symptomatic treatment. If the results of this trial are removed from the meta-analysis, and the remaining six studies are combined, there is a statistically significant reduction in the incidence of pneumonia in children receiving antibiotics (OR 0.17; 95% CI 0.05 to 0.65). The number needed to treat to prevent one episode of pneumonia is 24 patients. The incidence of other complications was significantly lower in children receiving antibiotics: purulent otitis media (OR 0.34; 95% CI 0.16 to 0.73) and tonsillitis (OR 0.08; 95% CI 0.01 to 0.72). There was no difference in the incidence of conjunctivitis (OR 0.39; 95% CI 0.15 to 1.0), diarrhea (OR 0.53; 95% CI 0.23 to 1.22) or croup (OR 0.16; 95% CI 0.01 to 4.06).

AUTHORS' CONCLUSIONS

This review suggests a beneficial effect of antibiotics in preventing complications such as pneumonia, purulent otitis media and tonsillitis in children with measles. On the basis of this review, it is not possible to give definitive guidelines on the type of antibiotic, duration, or the day of initiation. Use of penicillin or co-trimoxazole may be considered. There is a need to generate more evidence by well planned RCTs to answer these questions.

Viral Infections of the Lung

The lungs are among the most vulnerable to microbial assault of all organs in the body. From a contemporary vantage, lower respiratory tract infections are the greatest cause of infection-related mortality in the United States, and rank seventh among all causes of deaths in the United States.2,3 From a global and historic perspective, the scope and scale of lower respiratory tract infection is greater than any other infectious syndrome, and viral pneumonias have proven to be some of the most lethal and dramatic of human diseases. The 1918–1919 influenza pandemic, perhaps the most devastating infectious disease pandemic in recorded history, resulted in an estimated 40 million deaths worldwide, including 700,000 deaths in the U.S.4 The global outbreak of severe acute respiratory syndrome (SARS) during 2003, although considerably smaller in scale, resulted in 8098 cases and 774 deaths5 and is a dramatic contemporary example of the ability of viral pneumonias to rapidly disseminate and cause severe disease in human populations.

WITHDRAWN: Antibiotics for preventing pneumonia in children with measles

BACKGROUND

Measles causes more than a million deaths a year, of which most are children under five years of age who die from pneumonia.

OBJECTIVES

The objective of this review was to assess the effects of antibiotics given to children with measles on reducing pneumonia or mortality, and to assess whether antibiotics should be given to all children with measles in communities with a high fatality rate.

SEARCH STRATEGY

We searched MEDLINE (1966 - 1999), EMBASE (1980-1999) and the specialized trials register of the Acute Respiratory Infections Group in August 1999, and all relevant journals in the University of Melbourne medical library for the years 1935-46.

SELECTION CRITERIA

Randomised or controlled trials of antibiotics for children with measles.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Six trials with 1304 children were included. All but one of the trials were unblinded, and randomisation was either not described or was by alternate allocation. In four studies, the incidence of pneumonia in the control group was similar to that in the antibiotic prophylaxis group; in the other two studies, the incidence of pneumonia was unusually high in the control group so these children had a higher complication rate than the antibiotic group. Four of the 764 children given antibiotics died compared with one of the 637 controls.

AUTHORS' CONCLUSIONS

The quality of the trials reviewed was poor, and they provide very weak evidence for giving antibiotics to all children with measles. Available evidence suggests that antibiotics should be given only if a child has clinical signs of pneumonia or other evidence of sepsis.

Infection in Pediatric Acute Respiratory Distress Syndrome

Pediatric acute respiratory distress syndrome (ARDS) is a severe lung injury caused by pneumonia, sepsis, and trauma. ARDS results from inflammation and pulmonary capillary leak causing major changes in lung architecture and function. It has a low incidence, but its severity and duration cause major morbidity, mortality, and use of resources. Any organism can cause ARDS. Susceptible populations develop the syndrome more often and have worse outcomes. Aggressive diagnosis and intensive treatment are essential to good outcomes in ARDS caused by infection. The prognosis for survival is good, but morbidity after the syndrome is a major burden.

Morbilliviruses and human disease

Morbilliviruses are a group of viruses that belong to the family Paramyxoviridae. The most instantly recognizable member is measles virus (MV) and individuals acutely infected with the virus exhibit a wide range of clinical symptoms ranging from a characteristic mild self-limiting infection to death. Canine distemper virus (CDV) and rinderpest virus (RPV) cause a similar but distinctive pathology in dogs and cattle, respectively, and these, alongside experimental MV infection of primates, have been useful models for MV pathogenesis. Traditionally, viruses were identified because a distinctive disease was observed in man or animals; an infectious agent was subsequently isolated, cultured, and this could be used to recapitulate the disease in an experimentally infected host. Thus, satisfying Koch's postulates has been the norm. More recently, particularly due to the advent of exceedingly sensitive molecular biological assays, many researchers have looked for infectious agents in disease conditions for which a viral aetiology has not been previously established. For these cases, the modified Koch's postulates of Bradford Hill have been developed as criteria to link a virus to a specific disease. Only in a few cases have these conditions been fulfilled. Therefore, many viruses have over the years been definitely and tentatively linked to human diseases and in this respect the morbilliviruses are no different. In this review, human diseases associated with morbillivirus infection have been grouped into three broad categories: (1) those which are definitely caused by the infection; (2) those which may be exacerbated or facilitated by an infection; and (3) those which currently have limited, weak, unsubstantiated or no credible scientific evidence to support any link to a morbillivirus. Thus, an attempt has been made to clarify the published data and separate human diseases actually linked to morbilliviruses from those that are merely anecdotally associated.

Smallpox and measles: historical aspects and clinical differentiation

Smallpox and measles have ravaged native populations worldwide for centuries. Millions of people have succumbed to smallpox or measles or suffered from their effects. Clinicians wonder how their predecessors confused measles with smallpox. The difficulty was in differentiating smallpox and measles in their early phases, which had important public health implications. The prodromal rash of smallpox sometimes resembled measles. Clinicians through the ages learned to differentiate smallpox and measles in their early stages. Osler's careful clinical description of prodromal smallpox is a classic in infectious diseases. Koplik's appreciation of the diagnostic significance of the spots on the buccal mucosa was another advance in the early diagnosis of measles. The clinical features and effects of measles and smallpox on history are reviewed.

The clinical significance of measles: a review

Forty years after effective vaccines were licensed, measles continues to cause death and severe disease in children worldwide. Complications from measles can occur in almost every organ system. Pneumonia, croup, and encephalitis are common causes of death; encephalitis is the most common cause of long-term sequelae. Measles remains a common cause of blindness in developing countries. Complication rates are higher in those <5 and >20 years old, although croup and otitis media are more common in those <2 years old and encephalitis in older children and adults. Complication rates are increased by immune deficiency disorders, malnutrition, vitamin A deficiency, intense exposures to measles, and lack of previous measles vaccination. Case-fatality rates have decreased with improvements in socioeconomic status in many countries but remain high in developing countries.

Kingella kingae: from medical rarity to an emerging paediatric pathogen

In recent years, Kingella kingae has emerged as an important cause of invasive infections in young children, especially septic arthritis, osteomyelitis, spondylodiscitis, bacteraemia, and endocarditis, and less frequently lower respiratory tract infections and meningitis. The organism is part of the pharyngeal flora of young children and is transmitted from child-to-child. The clinical presentation of invasive K kingae disease is often subtle and laboratory tests are frequently normal. A substantial fraction of children with invasive K kingae infections have a recent history of stomatitis or symptoms of upper-respiratory-tract infection. The organism is susceptible to a wide array of antibiotics that are usually given empirically to young children including beta lactams, and with the exception of cases of endocarditis, the disease runs a benign clinical course. Although isolation and recognition of the organism is not difficult, clinicians and microbiologists should be aware of its fastidious nature. To optimise the recovery of K kingae, inoculation of synovial fluid specimens into blood culture vials is strongly recommended.

Measles: not just another viral exanthem

Measles is the most frequent cause of vaccine-preventable childhood deaths. Infants younger than the recommended age for vaccination are susceptible to the disease, and in developing countries they have a high risk of complications and mortality. Vaccine coverage in excess of 95% interrupts endemic transmission of measles in many countries, but achievement of such coverage almost always requires coordinated supplementary mass vaccination campaigns. There are substantial health gains if countries improve measles vaccine coverage, irrespective of whether or not high coverage is achieved; these gains include much lower measles complication and case fatality rates, long-term interepidemic duration, and possibly non-specific improvements in survival of children. Investigation into the cost-effectiveness of different strategies for measles control, including mass campaigns, two-dose schedules, and young-infant doses, would help countries to formulate control policies appropriate to their setting. Pneumonia is the most common fatal complication associated with measles, and at least 50% of measles-related pneumonias are due to bacterial superinfection. WHO has developed standard case management programmes for measles, but there are several unresolved clinical issues, including optimum indications for antibiotic treatment, the importance of intravenous immunoglobulin, the role of viral coinfection, and the risk of tuberculosis after measles. The priority in worldwide efforts to control measles is to lend support to poor countries, helping them to increase vaccine coverage and sustain improvements to vaccination infrastructure, and to address technical issues with respect to optimum vaccination schedules. Measles represents a specific challenge, whereby partnerships between high-income and developing nations would reduce child mortality in developing countries; such partnerships are not without incentive for high-income countries, since without them imported measles cannot be prevented.

Community-acquired pneumonia in immunocompromised patients. Opportunistic infections to consider in differential diagnosis

Immunocompromised persons are at increased risk for a large group of infections that are either uncommon or much less severe in the immunocompetent host. These opportunistic infections broaden the diagnostic considerations in differential diagnosis of community-acquired pneumonia in patients with immunodeficiencies. This article highlighted epidemiologic factors, clinical presentations, and treatment options for four selected opportunistic infections that represent varied classes of pathogens: nematodes (S stercoralis), mycoses (C neoformans), bacteria (P aeruginosa in patients with HIV infection), and viruses (measles virus).

Viral pneumonias in adults: radiologic and pathologic findings

Numerous viruses, including influenza virus, measles virus, Hantavirus, adenovirus, herpesviruses, varicella-zoster virus, cytomegalovirus, and Epstein-Barr virus, can cause lower respiratory tract infection in adults. Viral pneumonia in adults can be classified into two clinical groups: so-called atypical pneumonia in otherwise healthy hosts and viral pneumonia in immunocompromised hosts. Influenza virus types A and B cause most cases of viral pneumonia in immunocompetent adults. Immunocompromised hosts are susceptible to pneumonias caused by cytomegalovirus, herpesviruses, measles virus, and adenovirus. The radiographic findings, which consist mainly of patchy or diffuse ground-glass opacity with or without consolidation and reticular areas of increased opacity, are variable and overlapping. Computed tomographic findings, which are also overlapping, consist of poorly defined centrilobular nodules, ground-glass attenuation with a lobular distribution, segmental consolidation, or diffuse ground-glass attenuation with thickened interlobular septa. The radiologic findings reflect the variable extents of the histopathologic features: diffuse alveolar damage (intraalveolar edema, fibrin, and variable cellular infiltrates with a hyaline membrane), intraalveolar hemorrhage, and interstitial (intrapulmonary or airway) inflammatory cell infiltration. Clinical information such as patient age, immune status, community outbreaks, symptom onset and duration, and presence of a rash remain important aids in diagnosis of viral causes.

A review of measles virus

Measles virus is an epidemic disease with a worldwide distribution. Since the development of the live attenuated vaccine, the incidence of reported measles cases has declined by greater than 99% in the United States. Measles causes a systemic illness manifested by a characteristic prodrome and pathognomonic rash. Although usually a self-limited disease, measles can cause severe complications, especially in adults and the immunocompromised. We discuss a vaccination schedule for preschool and school-aged children. Recent research has demonstrated clinical benefit in patients with severe measles virus infections that are treated with ribavirin and vitamin A supplementation.

Kingella kingae infections in paediatric patients: 5 cases of septic arthritis, osteomyelitis and bacteraemia

Kingella kingae is a Gram-negative rod most often recognized as 1 of the organisms causing septic arthritis and osteomyelitis in children. Infection caused by K. kingae had not been diagnosed in Iceland until 5 cases were diagnosed at the Paediatric Department at the University Hospital of Iceland over a 1 year period. In this report we describe these 5 children with invasive infection caused by K. kingae (2 with septic arthritis, 1 with osteomyelitis, 1 with septic arthritis and osteomyelitis, and 1 with bacteraemia) and review the literature. All bacterial isolates were identified by the Bactec culture system.

Measles in pregnancy: maternal morbidity and perinatal outcome

OBJECTIVE

In this article, we studied the maternal morbidity and the perinatal outcome of 40 women who had measles in pregnancy and that was compared to 120 women who had pregnancy without measles and 37 women who had measles without pregnancy.

METHOD

The medical records of all the case and control subjects were reviewed and significance was tested at the 5% level.

RESULTS

The 40 cases of measles with pregnancy had significantly more hospital admission for pneumonia and fever when compared to cases of measles with no pregnancy (P < 0.001). The perinatal morbidity is significantly higher in cases of measles with pregnancy as expressed by the higher incidence of prematurity, neonatal hospital admission and length of stay in hospital (P < 0.003, P < 0.0005 and P < 0.0001, respectively).

CONCLUSION

Formulation of an appropriate strategy utilizing the available resources for measles vaccination is mandatory.

The high morbidity associated with a measles outbreak in a west Australian town

OBJECTIVE

To determine the effectiveness of the measles vaccine and to record the morbidity during a measles outbreak.

METHODOLOGY

A retrospective cohort study was carried out. It was a community-based study in Bunbury, Western Australia, between February and May 1994, of 53 cases of measles and their household contacts.

RESULTS

Of the 53 cases of measles, 24 were from one high school. Only two cases occurred in the high school class that had received the National Health and Medical Research Council of Australia recommended measles, mumps and rubella (MMR) booster 12 months earlier. Neither had been vaccinated. Vaccine effectiveness was 91% (95% confidence interval 67-97%). Ten cases had complications of measles and a further five were admitted to hospital. Doctors prescribed antibiotics to 29 cases and metoclopramide to five cases. One month elapsed between the day the index case became ill and the first notification to the community health centre.

CONCLUSIONS

The low herd immunity that led to this high school outbreak can be attributed to low vaccine coverage. There was a significant morbidity associated with this outbreak that may have been averted if earlier notification had occurred. The MMR booster dose should be offered to all 10-16 year olds to prevent high school outbreaks.

Measles pneumonitis

STUDY OBJECTIVE

To investigate the finding of increased alveolar-arterial (A-a) gradient in adult patients with measles who have normal results on both pulmonary auscultation and chest radiography.

DESIGN

Retrospective, descriptive case series.

SETTING

An urban county teaching hospital in southern California.

PARTICIPANTS

Consecutive adult patients with the clinical diagnosis of measles seen in the emergency department.

METHODS

Patients were considered to have pneumonitis if they had any of the following: ED diagnosis of pneumonia; an A-a gradient of more than 30 mm Hg; one or more infiltrates on chest radiograph.

RESULTS

Seventy-five patients, including 44 men and 31 women (median age, 25 years; 25% to 75% interquartile range [IQR], 20 to 28 years) were seen during the 36-month study period. Forty-three patients (57%; 95% confidence interval [CI], 45% to 69%) had pneumonitis, with a median A-a gradient of 42 mm Hg (IQR, 34 to 48 mm Hg). Twenty-seven of the 43 patients with pneumonitis (63%; CI, 48% to 77%) had both normal pulmonary auscultation findings and normal chest radiographs; this represented 36% of the study population (CI, 25% to 50%). Thirty-eight of the 43 patients with pneumonitis were admitted; one patient was later intubated after respiratory failure developed. Two of the 5 patients with pneumonitis who were sent home were admitted the following day for worsening symptoms. All 75 patients eventually did well.

CONCLUSION

A significant percentage of adult patients with measles presenting to an ED with both normal pulmonary auscultation and normal chest radiographs have increased A-a gradients. These patients warrant close follow-up and perhaps hospital admission.

Quality of published reports of the prognosis of community-acquired pneumonia

OBJECTIVE

To systematically assess the quality of published reports of the prognosis of community-acquired pneumonia using a formal quality assessment instrument.

DESIGN

Retrospective review of studies published during 1966-1991. ARTICLES: 108 articles related to the prognosis of community-acquired pneumonia retrieved by a computerized search.

INTERVENTION

All articles, blinded to author(s), journal title, year of publication, and study institution(s), were independently reviewed by two investigators using a ten-item quality assessment instrument designed to evaluate: 1) identification of the inception cohort (4 items), 2) description of referral patterns (1 item), 3) subject follow-up (2 items), and 4) statistical methods (3 items). Adherence to each of the ten individual quality items and an overall quality score were calculated for all articles and across three time periods.

MAIN RESULTS

Among all 108 articles that underwent quality assessment, 30 were published from 1966 to 1979, 61 from 1980 through 1989, and 17 from 1990 through 1991. The mean total quality score of all articles was 0.55 (range 0.22-0.90). There was a significant trend toward improvement in total quality scores over the three time periods (0.50 to 0.56 to 0.65; p < 0.001). However, several systematic errors in the study design or reporting of these studies were discovered throughout time: only 3.7% provided comparative information about nonenrolled patients, 28.7% determined whether the study institution was a referral center, 36.1% specified inclusion or exclusion criteria, and 45.5% used appropriate statistical analyses to adjust for more than one prognostic factor.

CONCLUSIONS

Despite improvement in overall quality of published articles, systematic errors exist in the design and reporting of studies related to the prognosis of community-acquired pneumonia. The quality assessment tool employed in this study could be used to guide the development of high-quality outcomes research in the future.

Clinical and laboratory features of measles in hospitalized adults

PURPOSE

Description of the epidemiology, morbidity, and mortality of hospitalized adults with typical measles.

PATIENTS AND METHODS

Retrospective case analysis of 33 adults who required acute care for complications of measles in a public hospital in Los Angeles, California. The diagnosis of measles was established on standard clinical or serologic grounds.

RESULTS

Of 68 patients (age greater than 14) with signs and symptoms of measles who presented for medical care, 33 (19 males and 14 females) required hospitalization; 18 were natives of the United States. The patient age was 26.1 +/- 7.3 (mean +/- SD) years; four patients, all natives of the U.S., were born before 1957. The duration of hospitalization was 6.8 +/- 8.8 days for all patients and 13.4 +/- 14.2 days for the nine patients who required intensive care unit (ICU) care. Six of the ICU patients required mechanical ventilation for 11.0 +/- 15.0 days; two deaths occurred among these patients. During the course of their illness, 7 of 25 (28%), 11 of 28 (39%), 6 of 28 (21%), and 5 of 16 patients (31%) had peak lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and creatine kinase values, respectively, that were greater than 5 times the upper limit of normal. Fifteen of 28 patients (54%) developed total serum calcium levels less than or equal to 2.0 mmol/L. Ten cases were serologically confirmed; 23 cases were diagnosed as probable measles on clinical grounds. There were no significant demographic, clinical, or laboratory differences between patients with confirmed and probable measles. No patients had characteristic manifestations of atypical measles. The sole immunocompromised patient died.

CONCLUSIONS

Measles in adults may result in severe, life-threatening complications that utilize substantial medical resources. Physicians need to appreciate the clinical presentations and manifestations of severe measles in adults and to provide measles vaccine to nonimmune adults during community-wide outbreaks.

Measles pneumonia. Treatment of a near-fatal case with corticosteroids and vitamin A

A 29-year-old woman experienced overwhelming rubeola pneumonia requiring endotracheal intubation and mechanical ventilation. Treatment with high-dose corticosteroids and vitamin A was accompanied by a prompt clinical response. Further investigation of this novel therapy is needed.

Patterns of measles pneumonitis

As a result of the enlarging pool of unvaccinated children and young adults, there has been an increase in serious measles pneumonitis in our areas. We recently examined autopsy and/or lung biopsy material from five children with fatal measles pneumonitis. Two patients were immunocompromised because of either prematurity or acute leukemia and died 13-16 days following onset of symptoms. Both had classic giant cell pneumonitis, with readily demonstrable intranuclear inclusions. Three other children without known immunocompromise had a more prolonged course. The lungs of these patients lacked the classic pattern and displayed instead a spectrum of less specific findings ranging from organizing diffuse alveolar damage to interstitial pneumonia with giant cells, but without viral inclusions. An accompanying necrotizing bronchiolitis was also present. Electron microscopy and/or detection of elevated measles-specific immunoglobulin M was necessary to confirm the diagnosis in these apparently immunocompetent patients. We conclude that the histologic features of fatal or serious measles pneumonitis are variable and depend to some extent on the immunocompetence of the host as well as the duration and tempo of the disease. Ancillary studies may be necessary to establish the diagnosis in cases lacking classic histopathologic features.

Osteoarticular infections due to Kingella kingae in children

By the description of two cases of osteoarticular infections due to Kingella kingae in two young children we wish to draw the attention of clinicians to invasive infections due to this micro-organism. Since its biological characterization in 1976, K. kingae has been increasingly reported as a human pathogen. Most common presentations are endocarditis, bacteraemia, septic arthritis, osteomyelitis and spondylodiscitis. Interestingly, osteorticular involvement is largely predominant in previously healthy children. From the literature, we reviewed 51 cases of K. kingae bone and joint infections, representing 23 cases of septic arthritis, 17 of osteomyelitis and 11 spondylodiscitis. Of the cases 88% occurred in children below 5 years of age and in all cases only one bone or joint was involved. An underlying disorder could be found in only 4 patients. Since these infections have a favourable outcome with intravenous antibiotic treatment, proper isolation and identification of K. kingae is essential.

Viral pneumonias. A diagnostic and therapeutic challenge

Viral pneumonias are both a diagnostic and a therapeutic challenge for primary care physicians. The illness should be suspected when an upper respiratory tract infection progresses to include dyspnea and cyanosis. Rapid diagnostic tests are now available to detect most of the viruses that cause pneumonias. Fortunately, viral pneumonias usually resolve without specific antiviral therapy; however, ribavirin is indicated for respiratory syncytial virus pneumonia in children and ganciclovir sodium (Cytovene) for cytomegalovirus pneumonia in immunocompromised patients. Acyclovir (Zovirax) is indicated for pneumonias due to herpes simplex virus and varicella-zoster virus infections. A high index of suspicion for bacterial superinfections is essential to reduce the risk of death from this complication.