Crippling lung disease after measles and adenovirus infection

Protection against severe infectious disease in the past

Before the 20th century many deaths in England, and most likely a majority, were caused by infectious diseases. The focus here is on the biggest killers, plague, typhus, smallpox, tuberculosis, cholera, typhoid, dysentery, childhood infections, pneumonia, and influenza. Many other infectious diseases including puerperal fever, relapsing fever, malaria, syphilis, meningitis, tetanus and gangrene caused thousands of deaths. This review of preventive measures, public health interventions and changes in behavior that reduced the risk of severe infections puts the response to recent epidemic challenges in historical perspective. Two new respiratory viruses have recently caused pandemics: an H1N1 influenza virus genetically related to pig viruses, and a bat-derived coronavirus causing COVID-19. Studies of infectious diseases emerging in human populations in recent decades indicate that the majority were zoonotic, and many of the causal pathogens had a wildlife origin. As hunter-gatherers, humans contracted pathogens from other species, and then from domesticated animals and rodents when they began to live in settled communities based on agriculture. In the modern world of large inter-connected urban populations and rapid transport, the risk of global transmission of new infectious diseases is high. Past and recent experience indicates that surveillance, prevention and control of infectious diseases are critical for global health. Effective interventions are required to control activities that risk dangerous pathogens transferring to humans from wild animals and those reared for food.

Lower respiratory infections by adenovirus in children. Clinical features and risk factors for bronchiolitis obliterans and mortality

Adenovirus (Ad) respiratory infections have a profound impact in Argentina. Severe chronic disease and a high mortality rate are observed in children after acute lower respiratory infections (ALRI) by Ad.

METHODS

A retrospective observational study was performed to describe clinical characteristics and to analyze risk factors for bronchiolitis obliterans (BO) and death in 415 children hospitalized with ALRI caused by Ad from March 1988 to May 2005.

RESULTS

Mean age of patients was 10.7 months (+/-9.2) Overall 80% of patients were healthy before ALRI. Forty-nine percent recovered, sequelae were observed in 36% and 15% died. Independent risk factors for BO were: >30 days of hospitalization (odds ratio (OR) 27.2, 95% confidence interval (CI) 14.6-50.9), multifocal pneumonia (OR 26.6, 95% CI 5.3-132) and hypercapnia (OR 5.6, 95% CI 3.5-9). Independent risk factors for death in acute stage of disease were: mechanical assistance (OR 121, 95% CI 18.2-814), multifocal pneumonia (OR 102, 95% CI 9.5-31.1), hypercapnia (OR 42.6, 95% CI 10.2-177.1), coagulation disorders (OR 17, 95% CI 8.25-35), neurological symptoms (OR 12.7, 95% CI 3.5-6.6) and co-infection with measles (OR 9.6, 95% CI 2.1-44.2).

CONCLUSIONS

High incidence of sequelae and mortality in previously healthy children after Ad infection was observed in a population of children from Argentina.

Adenovirus infections and lung disease

Adenovirus, particularly its E1A protein, has been investigated in the pathogenesis of chronic obstructive pulmonary disease (COPD). High levels of E1A DNA were found in the lungs of COPD patients, where its expression increased with disease severity. In lung epithelial cells, E1A increased intercellular adhesion molecule-1 and interleukin-8 expression, as well as nuclear factor-kappaB activation, in response to inflammatory stimuli. In addition to regulating the mediators that promote emphysema, E1A upregulates transforming growth factor-beta1 expression in bronchiolar epithelial cells and transforms lung epithelial cells to express mesenchymal markers. These results support its additional role in the airway remodeling process reported in COPD.

Increased risk of chronic suppurative lung disease after measles or pertussis in non-vaccinated children

We retrospectively analysed 23 children originating from Campania--Southern Italy--with recurrent pneumonia and chest high-resolution computed tomography (HRCT) proven bronchiectasis. In six patients (26%) who had not undergone measles or pertussis vaccination, recurrent pneumonia started after an episode of lower respiratory tract infection complicating pertussis (n=2) or measles (n=4), contracted at a mean age of 3.6 years. Thirty-three percent (2/6) and 67% (4/6) of the patients had bilateral or monolobar disease, respectively, while in two subjects (33%) bronchiectasis were found in all lobes. These findings indicate an increased risk of developing bronchiectasis after measles or pertussis.

High torquetenovirus loads are correlated with bronchiectasis and peripheral airflow limitation in children

BACKGROUND

The aim of the study was to evaluate the prevalence of torquetenovirus (TTV) infection in a group of children with recurrent lower respiratory tract infections and radiologic evidence of bronchiectasis. Correlations between TTV loads and severity of bronchiectasis and between TTV loads and lung function were evaluated.

METHODS

In 38 subjects, high-resolution computed tomography (HRCT) and plasma tests for TTV detection and quantification were done. In 21/38 subjects, spirometry was also performed.

RESULTS

TTV was found in 31/38 (81.6%) patients. The correlation between TTV loads and severity of bronchiectasis was statistically significant (r = 0.548; P = 0.01). TTV loads showed inverse correlation with FEF25-75% (r = -0.541; P = 0.011), and FEF25-75%/FVC (r = -0.512; P = 0.018). Inverse correlation was found also between severity of bronchiectasis and functional lung parameters: FEF25-75% (r = -0.635; P = 0.002), FEV1/FVC (r = -0.541; P = 0.011), and FEF25-75%/FVC (r = -0.645; P = 0.002).

CONCLUSIONS

This study demonstrated the high prevalence of TTV infection in children with bronchiectasis. Moreover, we have shown a significant correlation between TTV loads and airflow limitation within the peripheral airways, as well as between severity of bronchiectasis and decrease of lung function.

Development of pediatric pulmonology in the United Kingdom, Europe, and Australasia

The organization of medicine in Europe, the UK and the Commonwealth countries was always much less formal than in the USA for many years and pediatricians interested in pediatric lung disease and asthma often started off as adult internists or specialists in adult pulmonary medicine. The early leaders in developing a special interest in the breathing of children during the 1940s and 1950s were predominantly physiologists and clinicians who began to apply physiological techniques to the study lung function in healthy and sick infants and children. A major contribution to our understanding of the epidemiology of wheezing in children was the early establishment of a cohort study in Australia which is still yielding important information. It was during the early 1970s that pediatric pulmonary "politics" began to emerge in the UK when pediatricians interested in lung diseases began to arrange an informal society and meet regularly under the auspices of the British Paediatric Association. In fairly characteristic fashion, pulmonology in Europe was represented for a while by several different societies but due to the efforts of some dedicated enthusiasts there finally emerged the Paediatric Assembly of the European Respiratory Society (ERS) and its first Head, Max Zach, went to become President of the ERS itself. Despite some early doubts abut the future for pediatric pulmonology as a specialty in Europe and Australasia it is clearly flourishing as shown by the rising membership of the professional societies and the constant stream of high quality basic science and clinical publications.

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.

Investigation of the child with interstitial lung disease

Many disorders can affect the pulmonary interstitium in children. Although individual interstitial lung diseases are rare, the range of conditions encountered is wide. Interstitial disease is also seen increasingly as a consequence of the treatment of children having other primary problems including cancer, immunodeficiency and haemotological diseases, as well as in recipients of solid organ and bone marrow transplants. The management and prognosis of individual conditions is highly variable, thus it is essential to search for a precise diagnosis in every patient. High resolution computerised tomography (HRCT) and other less invasive investigations may be helpful in the management of patients. However, it is unusual to be able to make a firm diagnosis without a lung biopsy.

Do lower respiratory tract infections in early childhood cause chronic obstructive pulmonary disease?

The hypothesis that lower respiratory tract infections (LRTI) in early childhood lead to chronic obstructive pulmonary disease (COPD) in late adult life has been difficult to test. However, a unique opportunity arose when records were discovered in the counties of Hertfordshire and Derbyshire, England, that contained information about childhood LRTI recorded 60 to 70 years ago. The lung function of some men still living in these counties was examined. In Hertfordshire men, bronchitis or pneumonia in infancy was associated with reduced mean FEV1, adjusted for age and height. In Derbyshire men, pneumonia before 2 yr of age was associated with a large and highly significant reduction in mean FEV1, adjusted for age and height. These findings were independent of smoking and social class. These data support a causal relationship between LRTI in early life and subsequent COPD.

The epidemiology of measles: thirty years of vaccination

Measles is a highly infectious disease which has a major impact on child survival, particularly in developing countries. The importance of understanding the epidemiology of this disease is underlined by its ability to change rapidly in the face of increasing immunization coverage. Much is still to be learned about measles epidemiology and the best strategies for administering measles vaccines, as well as about the biological mechanisms of action of measles vaccines. However, it is clear that tremendous progress can be made in preventing death and disease from measles with existing knowledge about the disease, and by using the presently available vaccines and applying well tried methods of treating cases. Research in the coming decade may provide improved strategies and more effective vaccines for use in immunization programmes.

A randomized, controlled trial of vitamin A in children with severe measles

BACKGROUND

Measles kills about 2 million children annually, and there is no specific therapy for the disease. It has been suggested that vitamin A may be of benefit in the treatment of measles.

METHODS

We conducted a randomized, double-blind trial involving 189 children who were hospitalized at a regional center in South Africa because of measles complicated by pneumonia, diarrhea, or croup. The children (median age, 10 months) were assigned to receive either vitamin A (total dose, 400,000 IU of retinyl palmitate, given orally; n = 92) or placebo (n = 97), beginning within five days of the onset of the rash. At base line, the characteristics of the two groups were similar.

RESULTS

Although clinically apparent vitamin A deficiency is rare in this population, the children's serum retinol levels were markedly depressed (mean [+/- SEM], 0.405 +/- 0.021 mumols per liter [11.6 +/- 0.6 micrograms per deciliter]), and 92 percent of them had hyporetinemia (serum retinol level less than 0.7 mumols per liter [20 micrograms per deciliter]). Serum concentrations of retinol-binding protein (mean, 30.1 +/- 2.0 mg per liter) and albumin (mean, 33.4 +/- 0.5 g per liter) were also low. As compared with the placebo group, the children who received vitamin A recovered more rapidly from pneumonia (mean, 6.3 vs. 12.4 days, respectively; P less than 0.001) and diarrhea (mean, 5.6 vs. 8.5 days; P less than 0.001), had less croup (13 vs. 27 cases; P = 0.03), and spent fewer days in the hospital (mean, 10.6 vs. 14.8 days; P = 0.01). Of the 12 children who died, 10 were among those given placebo (P = 0.05). For the group treated with vitamin A, the risk of death or a major complication during the hospital stay was half that of the control group (relative risk, 0.51; 95 percent confidence interval, 0.35 to 0.74).

CONCLUSIONS

Treatment with vitamin A reduces morbidity and mortality in measles, and all children with severe measles should be given vitamin A supplements, whether or not they are thought to have a nutritional deficiency.

Adenovirus type 7 infections in children in New South Wales, Australia

This study describes our experience of adenovirus type 7 infection in children in New South Wales, Australia. Some aspects of the epidemiology of the infection are also recorded. A community outbreak, a hospital-ward outbreak, sporadic cases, and data from a centralised registry are described. Results of genome-type identification using restriction endonucleases are given. Adenovirus type 7b infection was associated with significant mortality and points to the need, previously expressed, for an adequate vaccine for high-risk infants. Continued surveillance of adenovirus type 7 infections worldwide is necessary to identify genome types so that appropriate vaccines can be developed.

Measles pneumonia: lung puncture findings in 56 cases related to chest X-ray changes and clinical features

Fifty-six African children with pneumonia following measles were investigated. Lung puncture identified bacteria by culture or countercurrent immune electrophoresis in 38% and blood culture with blood countercurrent immune electrophoresis (CIE) identified a further 17%, a bacterial diagnosis being made in a total 55%. Pneumococcus was the most common organism found, occurring in 30% of all measles pneumonias. More severe changes on chest X-ray at presentation were associated with higher rates of bacterial identification and worse outcome at 2 weeks. Chest X-ray changes were worse and bacterial identification was more common in poorly nourished children. Pneumothoraces occurred following lung puncture in 21% and surgical drainage was needed in 11%.

Factors predisposing to abnormal pulmonary function after adenovirus type 7 pneumonia

Adenoviruses are well known causes of respiratory illness in children. Long term sequelae reported with types 3, 7, and 21 include bronchiolitis obliterans, bronchiectasis, and the hyperlucent lung or McLeod syndrome. Twenty children admitted to hospital with adenovirus type 7 pneumonia between 1960 and 1978 were studied and compared with 20 controls admitted during the same period with adenovirus type 7 upper respiratory tract infections. Sixty five per cent of the pneumonia group had developed evidence of airways obstruction compared with 10% of controls. Young age at the time of pneumonia and a 'measles-like' illness before its onset increase the chance of developing long term pulmonary function abnormalities. Sex and family history of smoking or atopy do not influence outcome.

Bronchiectasis in childhood

Although bronchiectasis is relatively uncommon, it should be considered in a child with any of the following findings that persist: infiltrate on x-ray cough, purulent sputum, crackles or harsh breath sounds on auscultation of the chest, or hemoptysis. It is very likely that a pediatrician will encounter one or more children with this condition. This article deals with the pathogenesis, diagnosis, and treatment of bronchiectasis in childhood.

Adenovirus bronchiolitis in Manitoba: epidemiologic, clinical, and radiologic features

We reviewed our experience with 41 children hospitalized from 1974 to 1978 for adenovirus (ADV) bronchiolitis. Thirty-two patients (78 percent) were native Indians between four and 12 months old. In 18 of the 41 patients (43.9 percent) acute complications developed. The five fatal cases (12.2 percent) were confined to native children. The initial chest roentgenograms showed lobar consolidation in 35 patients (85.4 percent). Atelectasis developed in five (12.2 percent) during hospitalization. Sixteen of 25 patients (64 percent) with adequate radiologic follow-up examination had subsequent pneumonias or showed residual chronic changes. The reasons for the predilection of ADV bronchiolitis in native Indian children and the precise effect on subsequent airway function in survivors are unknown and require further study. We emphasize the importance of ADV as a cause of bronchiolitis in native Indian children. Furthermore, this report focuses attention on the contribution of this disease to the spectrum of chronic pulmonary disorders in the pediatric group.

Adenovirus type 21 bronchopneumonia in infants and young children

An epidemic of bronchopneumonia in infants and young children, with adenovirus type 21 infection, was observed in Auckland, New Zealand, in 1977. Eighteen children, four to 44 months of age, with clinical and radiologic evidence of bronchopneumonia are described. Several of the children were seriously ill but there were no deaths. When reviewed six to 12 months after diagnosis, six children had clinical signs and 13 had radiologic signs of residual pulmonary disease. There were no detectable pulmonary sequelae in two children. Three children were lost to follow-up and could not be evaluated. Adenovirus type 21 bronchopneumonia is a serious illness and an important cause of chronic bronchopneumopathy in infants and young children.