Clinical and laboratory features of measles in hospitalized adults

Influence of Lived Experiences on Public Responses to Future Diseases via (De)Sensitization of Concern

OBJECTIVES

Public responses to a future novel disease might be influenced by a subset of individuals who are either sensitized or desensitized to concern-generating processes through their lived experiences during the coronavirus disease 2019 (COVID-19) pandemic. Such influences may be critical for shaping public health messaging during the next emerging threat.

METHODS

This study explored the potential outcomes of the influence of lived experiences by using a dynamic multiplex network model to simulate a COVID-19 outbreak in a population of 2000 individuals, connected by means of disease and communication layers. Then a new disease was introduced, and a subset of individuals (50% or 100% of hospitalized during the COVID-19 outbreak) was assumed to be either sensitized or desensitized to concern-generating processes relative to the general population, which alters their adoption of non-pharmaceutical interventions (social distancing).

RESULTS

Altered perceptions and behaviors from lived experiences with COVID-19 did not necessarily result in a strong mitigating effect for the novel outbreak. When public disease response is already strong or sensitization is assumed to be a robust effect, then a sensitized subset may enhance public mitigation of an outbreak through social distancing.

CONCLUSIONS

In preparing for future outbreaks, assuming an experienced and disease-aware public may compromise effective design of effective public health messaging and mitigative action.

Clinical characteristics and outcomes of measles outbreak in adults: A multicenter retrospective observational study of 93 hospitalized adults in Greece

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Measles is an unresolved issue for unvaccinated or incompletely vaccinated adults.

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Data for outcomes, complications and risk factors in adults are limited.

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Pneumonitis and hepatic involvement are the most frequent complications in adults.

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Older age, low lymphocyte count and male sex are associated with pneumonitis.

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Case fatality ratio in adults is low despite the high frequency of complications.

Objectives

Measles outbreaks are increasingly reported among countries that were close-to-eliminate measles infection. There are few reports of clinical characteristics of measles in adults in the contemporary literature. In this study we aim to describe the clinical characteristics and complications of measles infection in hospitalized adults during the recent epidemic in Greece.

Methods

A multicentre observational retrospective study was conducted in three tertiary hospitals in Greece. All adult hospitalized patients (≥18 years old) with serologically confirmed and/or clinical features compatible with measles were included. Pediatric patients and patients with missing data were excluded.

Results

In total, 93 patients, 40 males (43 %) and 53 females (57 %), mostly young patients were included. Most of them (87 %) had no past medical history. Among women, 4 were pregnant. 56 (60.2 %) and 25 (26.9 %) patients reported either unknown or incomplete vaccination for measles. Ribavirin was administered in 8 (8.6 %) patients. Pneumonitis and hepatic involvement were the most common complications, occurring in 43 (46.2 %) and 75 (80.6 %) patients respectively. Pneumonitis was significantly associated with male sex, older age, lower lymphocyte counts and higher C-reactive protein (CRP) on admission. One pregnant woman suffered spontaneous fetal miscarriage and one patient died due to acute respiratory distress syndrome (ARDS) and high-risk pulmonary embolism.

Conclusion

Considerable proportions of incompletely vaccinated or unvaccinated adults have led to the re-emergence of measles in countries with reported close-to-elimination rates. Pneumonitis is a major complication among adults with measles. More studies are imperative in order to explore the role of immune paresis in measles.

Inpatient morbidity and mortality of measles in the United States

Background

Measles is an extremely contagious, vaccine-preventable infection that was officially declared eradicated in the US in 2000. However, measles outbreaks are increasingly occurring in the US. Measles cases have considerable morbidity requiring hospitalization, yet little is known about hospitalization and complications from measles in recent years.

Objectives

To analyze the frequency, predictors, costs and other outcomes of hospitalization for measles in the US.

Methods

The 2002–2016 Nationwide Inpatient Sample, containing a 20% sample of US hospitalizations (n = 96,568,625), was analyzed. Measles and comorbidities were defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) or ICD-10-CM codes. Multivariable survey logistic regression and linear regression models controlling for sociodemographic demographic factors were constructed to understand associations with organ-specific complications, and cost of care and length of stay, respectively.

Results

Overall, 1,018 measles hospitalizations occurred in 2002–2016, and hospitalizations increased over time. In multivariable logistic regression models, measles was associated with higher odds of gastrointestinal, hematologic, infectious, neurologic, ophthalmologic, pulmonary, and renal complications, with the strongest association observed with encephalitis (39.84 [16.51–96.12], P<0.0001). Increased length of stay (LOS) and similar cost of care (mean [95% CI]; 4.8 [4.4–5.4]; $7,438 [$6,446-$8,582]) were observed versus (vs.) all other admissions (4.5 [4.4–4.5]; P<0.01; $7,854 [$7,774-$7,935], P>0.05). There were 34 deaths in hospitalized measles patients; inpatient mortality was numerically higher in those with vs. without measles (proportion ± SEM: 3.3±1.2% vs. 2.3±0.01%, P = 0.333).

Limitations

Lack of outpatient or prescription data.

Conclusions

Measles continues to pose a substantial and preventable health care burden, with serious complications, hospitalization and inpatient mortality. Further studies are needed to improve the prevention and management of measles.

Measles Hospitalizations at a United States Children's Hospital 2011-2017

BACKGROUND

There are no recent descriptions of measles hospitalizations and complications in US children despite outbreaks within the past decade-including 2 in Minnesota (2011 and 2017). The objective of our study was to describe complications, hospital management and resource utilization for children hospitalized for measles at a US children's hospital.

METHODS

Retrospective case series of children (0-18 years of age) hospitalized for measles (observation/inpatient diagnosis code for measles) at Children's Minnesota, January 1, 2011, to September 1, 2017. Descriptive statistics were performed.

RESULTS

Thirty-three patients were included (7 from 2011 and 21 from 2017 outbreaks). Median age was 27 months (range, 6-95 months), 94% were Black or African American (73% Somali ethnicity), 88% had medical assistance and 91% were unvaccinated to measles. Poor feeding was a primary reason for admission (97%); additional complications included otitis media (42%), pneumonia (30%), tracheitis (6%) and keratitis (3%). Additional testing was common [chest radiographs (70%), blood cultures (64%), nonmeasles viral testing (42%)]. Seventy-three percent received antibiotics, 30% required oxygen and 21% received vitamin A. Median length of stay was 3.7 days (range, 1.1-26.2 days); 1 patient was readmitted. Median direct cost in 2017 was $5291 (interquartile range : $3907-$7519), and estimated total cost to the hospital for the 2017 outbreak was $1.3 million.

CONCLUSIONS

Clinicians should be aware of measles complications and treatment. Public and private health efforts should continue to focus on immunization, given significant implications of measles infections for patients and healthcare systems. Future studies may assess complications of measles across the United States as individual outbreaks often occur in specific populations, making generalization of results challenging.

Emerging and Rare Viral Infections in Transplantation

Immunocompromised patients such as those undergoing solid organ or hematopoietic stem cell transplantation are at substantial risk for infection with numerous pathogens. Infections with cytomegalovirus (CMV), herpes simplex virus (HSV), Epstein–Barr virus (EBV), and human herpesvirus-6 (HHV-6) are well-described complications of transplantation. As viruses previously believed to be quiescent through widespread vaccination (e.g., measles and mumps) reemerge and molecular diagnostic techniques are refined, rare and emerging viral infections are increasingly diagnosed in transplant recipients. This chapter will review the clinical manifestations, diagnosis, and potential antiviral therapies for these viruses in the transplant population.

Age-specific measles mortality during the late 19th–early 20th centuries

Measles mortality fell prior to the introduction of vaccines or antibiotics. By examining historical mortality reports we sought to determine how much measles mortality was due to epidemiological factors such as isolation from major population centres or increased age at time of infection. Age-specific records were available from Aberdeen; Scotland; New Zealand and the states of Australia at the end of the 19th and beginning of the 20th centuries. Despite the relative isolation of Australia, measles mortality was concentrated in very young children similar to Aberdeen. In the more isolated states of Tasmania, Western Australia and Queensland adults made up 14–15% of measles deaths as opposed to 8–9% in Victoria, South Australia and New South Wales. Mortality in Iceland and Faroe Islands during the 1846 measles epidemic was used as an example of islands isolated from respiratory pathogens. The transition from crisis mortality across all ages to deaths concentrated in young children occurred prior to the earliest age-specific mortality data collected. Factors in addition to adult age of infection and epidemiological isolation such as nutritional status and viral virulence may have contributed to measles mortality outcomes a century ago.

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.

Other viral infections in solid organ transplantation

Viral infections are a major cause of morbidity and even mortality in solid organ transplant recipients. This article reviews key aspects of infections in solid organ transplant recipients from respiratory viruses, such as influenza, polyomavirus, erythrovirus B19 and measles.

The eye in virology

This article outlines the ocular complications of viral infection. The emphasis is on the most common viruses encountered by the physician, and their clinical features and treatment are discussed while demonstrating the variation and often significant sequelae of ocular viral infection.

[Measles in adults: an emerging disease not sparing medical staff]

BACKGROUND

A large outbreak of measles is taking place in Europe and is related to a low vaccination coverage. Measles is observed in adults.

METHODS

We retrospectively studied all the consecutive cases of measles seen in adults between the 1/1/2007 and the 30/4/2009 in four Parisian hospitals.

RESULTS

Twenty-one patients were included. Six patients (29%) were health care workers (HCW) including five (83%) who were vaccinated. Twenty (95%) patients were hospitalized. All patients presented with febrile exanthema, cough and rhinitis in association with hepatic involvement in 71%. Neither death nor sequelae were reported.

CONCLUSION

Measles may occur in HCW, most of them being insufficiently covered by the vaccination. Therefore, since 2010, one injection of measles vaccine is now recommended in France, for HCW without history of measles or vaccination with two doses. Furthermore, adequate respiratory precautions should be taken when seeing patients with febrile exanthema and cough.

Challenges of T cell therapies for virus-associated diseases after hematopoietic stem cell transplantation

IMPORTANCE OF THE FIELD

Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for many hematological malignancies and genetic disorders. The majority of patients do not have a human leukocyte antigen (HLA) identical sibling donor, and alternative stem cell sources include HLA-matched or mismatched unrelated donors and haploidentical related donors. However, alternative donor HSCT are associated with three major complications i) graft rejection; ii) graft-versus-host disease (GvHD); and iii) delayed immune reconstitution leading to viral infections and relapse.

AREAS COVERED IN THIS REVIEW

Graft rejection and the risk of GvHD can be significantly reduced by using intensive conditioning regimens, including in vivo T cell depletion as well as ex vivo T cell depletion of the graft. However, the benefits of removing alloreactive T cells from the graft are offset by the concomitant removal of T cells with anti-viral or anti-tumor activity as well as the profound delay in endogenous T cell recovery post-transplant. Thus, opportunistic infections, many of which are not amenable to conventional small-molecule therapeutics, are frequent in these patients and are associated with significant morbidity and high mortality rates. This review discusses current cell therapies to prevent or treat viral infections/reactivations post-transplant.

WHAT THE READER WILL GAIN

The reader will gain an understanding of the current state of cell therapy to prevent and treat viral infections post-HSCT, and will be introduced to preclinical studies designed to develop and validate new manufacturing procedures intended to improve therapeutic efficacy and reduce associated toxicities.

TAKE HOME MESSAGE

Reconstitution of HSCT recipients with antigen-specific T cells, produced either by allodepletion or in vitro reactivation, can offer an effective strategy to provide both immediate and long-term protection without harmful alloreactivity.

Viruses in the Intensive Care Unit (ICU)

Whereas viruses are not usually considered to be important causes of ICU admission this review has demonstrated this perception to be incorrect. Viruses and their manifestations differ from continent to continent and hemisphere to hemisphere and it is essential that the intensivist be familiar with diagnosis and management of these ubiquitous organisms.

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.

Acute renal failure with neurological involvement in adults associated with measles virus isolation

BACKGROUND

Three people with clinical manifestations of acute renal failure with neurological involvement of unknown cause were admitted to a hospital in Mumbai, India. We describe clinical presentations and investigations of the cause.

METHODS

We analysed case reports and laboratory findings for the patients (age 37-43 years, two men, one woman) that were provided by the clinicians in charge. Serum and cerebrospinal fluid were tested for viral cause by IgM ELISA to Japanese encephalitis, West Nile fever, dengue, and measles. Samples were inoculated in vero-cell culture for virus isolation. The virus isolates were confirmed with indirect immunofluoresence with antimeasles immune sera and mouse monoclonal antibodies to measles HA and F proteins and with neutralisation tests using antimeasles immune sera.

FINDINGS

Clinical features were fever, vomiting, oliguria or anuria, bilateral facial weakness, impaired hearing, blindness, proximal and distal areflexic limb paralysis, and respiratory paralysis. No patient had a macropapular rash. Blood urea nitrogen (4.64-27.8 mmol/L) and creatinine (601.1-1105.0 micromol/L) were high, and cerebrospinal fluid contained high concentrations of proteins and pleocytosis. Kidney biopsy samples in two patients showed severe interstitial nephritis. IgM antibodies to measles were found in blood and cerebrospinal fluid. Vero-cell cultures from serum and cerebrospinal fluid of one patient and cerebrospinal fluid of two patients, showed cytopathic effects characteristic of measles.

INTERPRETATION

Unusual manifestations of acute renal failure with neurological involvement associated with measles virus in adults presenting without rash was confirmed. Our findings may affect the development of measles-elimination programmes.

Adult Travelers with HIV Infection

The number of HIV-infected persons who travel to the developing world is increasing. Pleasure, business, other work, and illness or death in families brings these special travelers to all corners of the world.1,2 Health care providers should ask patients who are seeking advice whether they are HIV-infected or at risk so that these travelers can be adequately protected and prepared. In most instances international travel is feasible, but in some cases itineraries may be modified or additional recommendations may be given to make trips safer and more enjoyable. This paper reviews the health problems that persons with HIV infection may face during international travel, and their prevention.

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.